Five Points at Lake Highlands Nursing and Rehab

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the<BR/>Resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. <BR/>The facility failed to ensure Resident #1 had an environment free of accident hazards by not keeping her bed at a safe angle while being fed thereby preventing a choking hazard. <BR/>This failure affected residents by placing them at risk for choking and aspiration. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADL to include feeding assistance and impaired vison. <BR/>Review of Resident #1's Care Plan, dated 8/28/2023, disclosed Resident #1 was ADL Performance Deficient requiring total assistance to eat, bath, and reposition in bed. <BR/>In an observation on 1/20/2024, at 1:15 PM, Resident #1 was observed being fed by CNA-A while Resident #1's bed angle was significantly below a 45-degree angle. Resident #1's neck was observed turned to her left side, at a low angle, while CNA-A was feeding her meatballs and spaghetti. Resident #1's bed angle was observed to never change the entire time Resident #1 was being fed. <BR/>In an interview with the Administrator on 1-20-2024, at 7:00 PM, it was disclosed that his expectation of the angle a resident should be fed at, while lying in bed, depends on the diagnosis, catering to the resident's preferences, and safety. The Administrator's expectation was the feeder should try to prevent aspiration and pain. <BR/>In an interview with the DON on 1-20-2024, at 7:38 PM, it was disclosed that her expectation for the angle of a bed to be at, when a resident was being fed by staff, was for the bed to be between 30-45-degree angle. The DON stated that some family members have requested a resident's bed to be at a 60-degree angle while being fed. The DON stated that it was the responsibility of the nursing staff to make sure a resident's bed was at a safe angle for feeding. The DON stated it was also the responsibility of the CNA's, doing the feeding, to ensure the resident's bed was at a safe angle for feeding but mostly the responsibility falls on the nurses.<BR/>Record review of the facility's policy on Feeding, Assistive/Complete, that is non-dated, stated . It is important to allow and encourage as must independence in self-feeding as possible to enhance self-worth and provide optimal control of daily living activities. The goal is for <BR/>1. The resident will achieve maximal participation in daily self-feeding .The Procedures are <BR/>3. Explain the procedure and expected results to the resident .<BR/>5. Position the resident for comfort. Use high [NAME]=s while sitting in bed (High [NAME] was a supine position in which an individual lies on their back on a bed, with the head of the bed elevated between 60-90 degrees, and the legs of the patient can be either straight or bent at the knees).<BR/>6. Provide a pleasant environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 4 out of 9 residents (Resident #3, Resident #4, Resident #7 and Resident #8) reviewed for dental services. <BR/>The facility failed to provide timely dental services for Resident #3, Resident #4, Resident #7, and Resident #8 from December 2023 through May 17, 2024. <BR/>This failure could place residents at risk of oral complications, dental pain, and diminished quality of life. <BR/>Findings included: <BR/>1) Record review of Resident #3's face sheet showed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Chronic Osteomyelitis (a bone infection that occurs when an infection does not clear up after treatment), Paraplegia (leg paralysis), Congestive Heart Failure (chronic condition in which the heart does not pump blood as well as it should), Cerebral Infarction (occurs as a result of disrupted blood flow to the brain due to problems with blood vessels that supply it), Type 2 Diabetes Mellitus (long term condition where body has trouble controlling blood sugar and using it for energy), Muscle Weakness, Lack of Coordination and Osteomyelitis of Vertebra (a rare bone infection that affects the vertebrae, or spinal discs). <BR/>Record Review of Resident #1's quarterly MDS dated [DATE], revealed a BIMS score of 15 which was cognitively able to make choices and decisions for themselves. <BR/>Record Review of Resident #1's Care Plan dated 4/15/24, showed resident has an ADL self-care performance deficit and personal hygiene requires setup. Also, the care plan stated the resident had behaviors which include non-compliance with diabetic diet- eats high sugar, high carbohydrate diet often ordering restaurant or fast food up to three meals daily. <BR/>Interview on 5/17/24 at 11:44 a.m. with Resident #1 stated she told the social worker about a dental issue she had in December 2023. Resident #1 said it would be taken care of next week on 5/25/24. She stated she had let the social worker know about the dental issue and asked persistently to be seen by the dentist. Resident #1 did not tell me what the dental issue was as she stated it was being taken care of next week. <BR/>2) Record Review of Resident #4's face sheet showed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves), Protein-Calorie Malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), Lack of Coordination, Cognitive Communication Deficit (trouble participating in conversations), Dysarthria (a motor speech disorder that occurs when someone cannot control muscles used for speaking) and Anarthria (most severe form of dysarthria and results in complete loss of speech), Lack of Coordination, Muscle Wasting and Atrophy (gradual loss of muscle mass and strength), Contracture (shortening of muscles, tendons, skin or soft tissues that causes joints to shorten and become stiff, preventing normal movement), Major Depressive Disorder, Pain, Anxiety Disorder, and Insomnia (sleep disorder in which one has trouble falling asleep, staying asleep or getting quality sleep). <BR/>Record Review of Resident #4's quarterly MDS dated [DATE] revealed a BIMS score of 12 which is slightly cognitively impaired. <BR/>Record Review of Resident #4's Care Plan dated 1/19/24, revealed she has an ADL Self Care Performance Deficit and Personal hygiene requires total assistance. <BR/>Record Review of Resident #4's Oral Care showed she was getting oral care two times a day over the last 30 days. <BR/>Interview and observation on 5/17/24 at 12:02 p.m. with Resident #4 stated she did not get her teeth brushed often but would like them brushed every evening. Resident #1 said she did ask for her teeth to be brushed more often, but it usually did not happen. Resident #1 said the dentist came to the facility. She did not remember the last time she saw the dentist but said it had been awhile. Observation of Resident #4's lower teeth had plaque buildup on them. <BR/>3) Record Review of Resident #7's face sheet revealed a [AGE] year-old man, who was admitted on [DATE]. Diagnoses included: Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), Muscle Weakness, Cognitive Communication Deficit (trouble participating in conversations), Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Insomnia (trouble participating in conversations), Pain, and Major Depressive Disorder. <BR/>Record Review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS of 13 which was cognitively able to make choices and decisions for themselves. <BR/>Record Review of Resident #7's Care Plan dated 2/12/24 showed he has Hypertension and an ADL self-care performance deficit due to limited mobility. Also, the care plan revealed resident was a smoker. <BR/>Interview on 5/17/24 at 12:42 p.m. with Resident #7 stated he needed his teeth fixed. He stated the dentist gave him a cleaning but did not fix his mouth. Resident #7 said his lower right side of his mouth hurts. He tried to eat around that area but if he did eat in that area, his gums would be sore for two days. Resident #7 said he saw the dentist three times, had told the dentist about the issues each time, but he had never fixed his teeth. Resident #7 said he had let the social worker know about his teeth issues and she scheduled the visits, but it has not been fixed. <BR/>4) Record Review of Resident #8's face sheet revealed a [AGE] year-old woman, who was admitted on [DATE]. Diagnoses included: Ataxia (impaired coordination), Disorientation (a mental state that causes confusion about time, place or identity), Generalized Anxiety Disorder, Cerebrovascular Disease (conditions that affect blood flow to your brain), Dizziness, Osteomyelitis (bone infection), Muscle Weakness and Monoplegia of Upper Limb Affecting Right Dominant Side (a type of paralysis that affects one limb, usually an arm, on one side of the body). <BR/>Record Review of Resident #8's quarterly MDS dated [DATE] revealed a BIMS of 15 which was cognitively able to make choices and decisions for themselves. <BR/>Record Review of Resident #8's Care Plan dated 1/19/24 showed she had poor balance and unsteady gait. Also, Resident #8 had and ADL self-care performance deficit. <BR/>Interview on 5/17/24 at 12:52 p.m. with Resident #8 stated she had a cavity on her lower left side. She had told the social worker about the issue. She got an appointment and stated she waited in the lobby for her appointment for 2 &frac12; hours. Then, she was told the dentist was done for the day. She was not sure of the date but said it was about 5 months ago. Resident #8 told the social worker about the issue she had and was put on the list to see the dentist. <BR/>Interview on 5/17/24 at 12:21 p.m. with RN A stated she would let the social worker/SW know if there were any dental issues as the SW scheduled the dental appointments. <BR/>Interview on 5/17/24 at 2:44 p.m. with LVN B stated if a resident was having dental issues, she would do a referral to the SW. She stated the SW contacted the dentist for a dental appointment. LVN B said she would also contact the doctor if the resident was in pain.<BR/>Interview on 5/17/24 at 2:55 p.m. with CNA C stated if a resident had dental problems, she would let her nurse know. <BR/>Interview on 5/17/24 at 2:59 p.m. with LVN D stated if a resident had dental issues, she would notify the doctor if they were in pain and let the SW know. LVN D stated there was a mobile dentist that came to the facility. She stated the mobile dentist was there last month. LVN D stated a resident would be placed on a wait list if it was not urgent. <BR/>Interview on 5/17/24 at 3:02 p.m. with CNA E stated if a resident had dental needs, she would document it and let her nurse know. <BR/>Interview on 5/17/24 at 3:07 p.m. with SW stated if a resident was having dental pain, a nurse would let her know and she would call the dental company. The dental company would do a facetime call with the resident and then come out. SW stated the dental company comes out every other month or every 2 months. The dental company was a new company and has only been in business 5 months. SW stated she has not heard of the dental company leaving before seeing all residents on the list for that day. <BR/>Interview on 5/17/24 at 5:31 p.m. with Director of Nursing/DON stated the social worker made the dental appointments. If a resident was in pain, they will contact the doctor. The dentist will give antibiotics if there was an infection. The dental service comes on a regular basis. She believes they come every 4 - 6 weeks. The dentist came right away if there was a dental emergency. <BR/>Record Review of the mobile dental service, list of residents that were to be seen as of 5/15/2024 for facility with Date of Visit: 5/24/2024 showed, Resident #3 is on the list to be seen and was due for an exam, prophy (treatment that prevents disease) and x-rays. Also, the list showed Resident #4 was due for an initial exam and prophy. Furthermore, the list showed Resident #7 was due for an exam and extraction (s). <BR/>Record Review of facility policy Dental Services dated 2003, under Policy stated, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.<BR/>Record Review of facility Resident Rights undated, stated The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy.<BR/>A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. <BR/>Also, under Respect and Dignity of Resident Rights stated The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to treat each resident with respect, dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 (Resident #1) observed for resident rights. <BR/>The facility failed to ensure Resident #1 was treated with dignity and respect while being fed by a staff member.<BR/>This failure can damage resident's self-esteem and self-worth causing negative psychosocial outcomes affecting their health. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney (hard deposits made of minerals and salts that form inside your kidneys), muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADL to include feeding assistance and impaired vison. <BR/>Review of Resident #1's Care Plan, dated 8/28/2023, disclosed Resident #1 was ADL Performance Deficient requiring total assistance to eat, bath, and reposition in bed. <BR/>In an observation, on 1/20/2024, at 1:12 PM, CNA-A was observed bringing food to Resident #1's bedroom and feeding Resident #1 in a sitting position at eye level. <BR/>Resident #1 was observed asking CNA-A questions about the food she was being served and CNA-A was observed not answering Resident #1. Resident #1 was observed asking several times to CNA-A Why don't you answer me. CNA-A was observed saying why don't you just open up your mouth and just eat. CNA-A was observed for several minutes feeding Resident #1 and at the same time he had his attention on his cell phone. At one point, CNA-A was observed sitting beside Resident #1s bed, with the food tray next to him, playing on his cell phone and not feeding Resident #1. CNA-A was observed to begin feeding Resident #1 again with his right hand while playing on his cell phone with his left hand. This was observed to continue until Resident #1 had finished eating. CNA-A was observed not answering any of Resident #1's questions while he was in her room. <BR/>In an interview with Resident #1 on 1-20-2024, at 1:55 PM, just after being fed by CNA-A, it was revealed that CNA-A was rude to Resident #1. In this interview it was revealed that CNA-A has fallen asleep while feeding Resident #1 and snored to the point Resident #1 had to wake CNA-A up to keep feeding Resident #1. Resident #1 said this was rude of CNA-A to ignore me. <BR/>In an interview with the Administrator on 1-20-2024, at 7:00 PM, it was disclosed that the Administrator's expectation was for the staff to treat residents like their own family, when they are feeding residents. <BR/>Record review of the facility's policy on Feeding, Assistive/Complete, that is non-dated, stated . It is important to allow and encourage as much independence in self-feeding as possible to enhance self-worth and provide optimal control of daily living activities. The goal is:<BR/>1. The resident will achieve maximal participation in daily self-feeding .<BR/>The Procedures are:<BR/>3. Explain the procedure and expected results to the resident .<BR/>5. Position the resident for comfort. Use high Fowler=s while sitting in bed .<BR/>6. Provide a pleasant environment.<BR/>Record review of the facility's policy on Resident Rights, dated 4-21-2023, states:<BR/>1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:<BR/>a. a dignified existence;<BR/>b. be treated with respect, kindness, and dignity; .<BR/>f. communication with and access to people and services, both inside and outside the <BR/>facility<BR/>p. be informed of, and participate in, his or her care planning and treatment .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 5 of 9 residents (Residents #1, #2, #7, #8, #9) reviewed for environment. <BR/>The facility failed to ensure Residents #1, #2, #7, #8, and #9 had hot water for washing and bathing in their rooms.<BR/>This failure affected residents by placing them at risk for a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes.<BR/>In an observation of Resident #1's bathroom on 1-20-2024 at 4:40PM, it was discovered that Resident #1 did not have hot water in her bathroom. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that there wasn't hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of assistance with ADL. <BR/>In an observation of Resident #2's bathroom, on 1-20-2024, at 5:00 PM, it was confirmed that Resident #2 had no hot water in her bathroom. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia, and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis. <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was conveyed that Resident's bathroom hasn't had hot water for weeks. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>In an observation of Resident #7's bathroom, on 1-20-2024, at 5:20 PM, it was confirmed Resident #7's bathroom was without hot water. <BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 has a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8 stated his room hasn't had hot water for over a week. <BR/>In an observation of Resident #8's bathroom, on 1-20-2024, at 5:20PM, it was revealed that Resident #8 did not have hot water in his bathroom. <BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 has a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism, unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room hasn't had hot water for over a week. <BR/>In an observation of Resident #9's bathroom, on 1-20-2024 at 6:10 PM, it was confirmed that Resident #9 had no hot water in his bathroom. <BR/>In an interview with the Director of Maintenance by phone, it was revealed he is offsite up north. The Director of Maintenance said there was hot water in the lines, but he thinks the mixing valve is defective, which could be causing the water, in the 300 area, to not be hot in the resident's rooms. However, he was not sure if that was the problem. The Director of Maintenance said they were waiting on a part to come in Monday to see if that fixes the problem. The Director of Maintenance stated that the water temperature has dropped below 102 degrees Fahrenheit, in the line, but not over 2 weeks. The Director of Maintenance would not say how long the water temperature has been a problem. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was revealed that his expectation was that residents have hot water in their bathrooms. The Administrator stated that one of their tankless water heaters had to be replaced and the control valve that adjusts the heat wasn't working. The Administrator stated that a part has been ordered and should be at the facility next week. The Administrator said was the Director of Maintenance's responsibility to ensure residents have hot water in their bathrooms. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was learned that her expectation was that residents be taken to units that do have hot water to use. The DON stated that when residents do not have hot water in their restrooms, it could be an infection control issue. The DON said the facility had a problem with hot water in the 300-room domain. The DON stated it was everyone's responsibility to make sure residents have hot water and report it when residents don't. <BR/>Record Review of the facility's undated Hot Water Systems Policy stated the hot water system will be checked daily to include shower temperatures. The water temperatures should be maintained at 100 degrees Fahrenheit minimum .<BR/>13.Temperature readings will be recorded on the water temperature log. <BR/>14. <BR/>The hot water tanks should be adjusted accordingly with readings that are too high or too low. Adjustments will be noted on the water temperature log.<BR/>15. <BR/>After adjustments are made, the temperature must be rechecked within thirty minutes of the adjustment. If the water continues to be too hot or too cold, the Administrator should be notified immediately.<BR/>16. <BR/>The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers.<BR/>The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled.<BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADLs to include feeding assistance and impaired vison. <BR/>Record Review of the shower log, in the 300-domain area, for Resident #1 revealed the last time Resident #1 took a shower was 12/26/2023. There were no other shower entries for Resident #1 from 12-27-2023 through 1-20-2024. <BR/>In an interview with Resident #1, on 1/20/2024, at 1:12 PM, revealed that Resident #1 had not had a shower in 3 weeks. Resident #1 stated she wanted to take a shower at least once a week. <BR/>Record review of Resident #5's Face Sheet dated 1-20-2024, showed an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had a primary diagnosis of pneumonia unspecified organism, chronic atrial fibrillation unspecified (the heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles)), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and reduced mobility. <BR/>Record Review of the facility's ADL Dependent Resident Report dated 1-20-2024, indicated Resident #5 was an ADL Dependent Resident of the facility and needs assistance bathing. <BR/>In an interview with Resident #5, on 1/20/2024, at 4:10 PM, it was conveyed that Resident #5 needed ADL assistance as she loses her balance. Resident #5 revealed she had not been bathed as often as she wanted to. Resident #5 wanted to get showered at least twice a week. Resident #5 stated that she had gone over a week without getting a bed-bath. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that the showers in the 300-domain hall, has not had hot water. Resident #2 conveyed that she has not had a shower in 3 weeks and there has not been hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of ADL assistance. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis (a condition in which too much acid accumulates in the body). <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was expressed that the Resident's bathroom had not had hot water for weeks and Resident #7 had not had a shower for over a week or two. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>Record review of the shower log for Resident #7 disclosed that Resident #7 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 had a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8's room had not had hot water for over a week and Resident #8 had not had a shower in a week or two. Resident #8 would like to get a shower every couple of days.<BR/>Record review of the shower log for Resident #8 disclosed that Resident #8 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 had a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism (a disorder of the central nervous system that affects movement), often including tremors., unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room had not had hot water for over a week and Resident #9 had not had a shower in over a week. Resident #9 stated that he would like to have a shower every other day and he did not want to take a cold shower. <BR/>Record Review of the shower log for Resident #9 indicated Resident #9 refused a shower on 1-18-2024. There were no other shower logs for Resident #9 for the year of 2024. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was disclosed that his expectation was that residents were offered showers in other units, even if their unit, does not currently have hot water. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was revealed that her expectation was that a staff members would take a resident to another unit to get a shower, if the resident's unit does not have hot water. The DON stated that staff, in the 300 unit, where the hot water was temporarily out, have been instructed to take residents, who want a shower, to another unit. The DON stated that it was her expectation that staff did not offer a cold shower to a resident if there is a shortage of hot water. <BR/>Record Review of the facility's undated Bath, Tub/Shower Policy stated .The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the<BR/>Resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. <BR/>The facility failed to ensure Resident #1 had an environment free of accident hazards by not keeping her bed at a safe angle while being fed thereby preventing a choking hazard. <BR/>This failure affected residents by placing them at risk for choking and aspiration. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADL to include feeding assistance and impaired vison. <BR/>Review of Resident #1's Care Plan, dated 8/28/2023, disclosed Resident #1 was ADL Performance Deficient requiring total assistance to eat, bath, and reposition in bed. <BR/>In an observation on 1/20/2024, at 1:15 PM, Resident #1 was observed being fed by CNA-A while Resident #1's bed angle was significantly below a 45-degree angle. Resident #1's neck was observed turned to her left side, at a low angle, while CNA-A was feeding her meatballs and spaghetti. Resident #1's bed angle was observed to never change the entire time Resident #1 was being fed. <BR/>In an interview with the Administrator on 1-20-2024, at 7:00 PM, it was disclosed that his expectation of the angle a resident should be fed at, while lying in bed, depends on the diagnosis, catering to the resident's preferences, and safety. The Administrator's expectation was the feeder should try to prevent aspiration and pain. <BR/>In an interview with the DON on 1-20-2024, at 7:38 PM, it was disclosed that her expectation for the angle of a bed to be at, when a resident was being fed by staff, was for the bed to be between 30-45-degree angle. The DON stated that some family members have requested a resident's bed to be at a 60-degree angle while being fed. The DON stated that it was the responsibility of the nursing staff to make sure a resident's bed was at a safe angle for feeding. The DON stated it was also the responsibility of the CNA's, doing the feeding, to ensure the resident's bed was at a safe angle for feeding but mostly the responsibility falls on the nurses.<BR/>Record review of the facility's policy on Feeding, Assistive/Complete, that is non-dated, stated . It is important to allow and encourage as must independence in self-feeding as possible to enhance self-worth and provide optimal control of daily living activities. The goal is for <BR/>1. The resident will achieve maximal participation in daily self-feeding .The Procedures are <BR/>3. Explain the procedure and expected results to the resident .<BR/>5. Position the resident for comfort. Use high [NAME]=s while sitting in bed (High [NAME] was a supine position in which an individual lies on their back on a bed, with the head of the bed elevated between 60-90 degrees, and the legs of the patient can be either straight or bent at the knees).<BR/>6. Provide a pleasant environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the<BR/>Resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. <BR/>The facility failed to ensure Resident #1 had an environment free of accident hazards by not keeping her bed at a safe angle while being fed thereby preventing a choking hazard. <BR/>This failure affected residents by placing them at risk for choking and aspiration. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADL to include feeding assistance and impaired vison. <BR/>Review of Resident #1's Care Plan, dated 8/28/2023, disclosed Resident #1 was ADL Performance Deficient requiring total assistance to eat, bath, and reposition in bed. <BR/>In an observation on 1/20/2024, at 1:15 PM, Resident #1 was observed being fed by CNA-A while Resident #1's bed angle was significantly below a 45-degree angle. Resident #1's neck was observed turned to her left side, at a low angle, while CNA-A was feeding her meatballs and spaghetti. Resident #1's bed angle was observed to never change the entire time Resident #1 was being fed. <BR/>In an interview with the Administrator on 1-20-2024, at 7:00 PM, it was disclosed that his expectation of the angle a resident should be fed at, while lying in bed, depends on the diagnosis, catering to the resident's preferences, and safety. The Administrator's expectation was the feeder should try to prevent aspiration and pain. <BR/>In an interview with the DON on 1-20-2024, at 7:38 PM, it was disclosed that her expectation for the angle of a bed to be at, when a resident was being fed by staff, was for the bed to be between 30-45-degree angle. The DON stated that some family members have requested a resident's bed to be at a 60-degree angle while being fed. The DON stated that it was the responsibility of the nursing staff to make sure a resident's bed was at a safe angle for feeding. The DON stated it was also the responsibility of the CNA's, doing the feeding, to ensure the resident's bed was at a safe angle for feeding but mostly the responsibility falls on the nurses.<BR/>Record review of the facility's policy on Feeding, Assistive/Complete, that is non-dated, stated . It is important to allow and encourage as must independence in self-feeding as possible to enhance self-worth and provide optimal control of daily living activities. The goal is for <BR/>1. The resident will achieve maximal participation in daily self-feeding .The Procedures are <BR/>3. Explain the procedure and expected results to the resident .<BR/>5. Position the resident for comfort. Use high [NAME]=s while sitting in bed (High [NAME] was a supine position in which an individual lies on their back on a bed, with the head of the bed elevated between 60-90 degrees, and the legs of the patient can be either straight or bent at the knees).<BR/>6. Provide a pleasant environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers for one of 3 residents (Resident #7) reviewed for enteral nutrition. <BR/>LVN D failed to check for residual volume prior to medication administration. <BR/>This failures could place residents at risk for metabolic abnormalities, medical complications, or a decline in health. <BR/>Findings included:<BR/>Record review of Resident #7's face sheet, dated 07/07/23, reflected a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Gastrostomy status (an opening in the stomach at the abdominal wall made surgically to introduce food), dysphasia (speech disorder) and cerebral palsy (damage that occurs to the developing brain, most often before birth).<BR/>Record review of Resident #7's annual MDS Assessment, dated 05/03/23, reflected Resident #7 BIMS score was blank which indicated severe cognitive impairment. Resident #7 required extensive to total assistance with ADLs with two persons assist. Further review revealed Resident #7 had a feeding tube.<BR/>Record review of Resident #7's medication administration and treatment record reflected there was no specific order for checking for residual. Enteral Feed Order every shift Head of Bed raised 30 to 45 degrees during Administration of Enteral formula, Water or Medication.<BR/>Observation on 11/06/23 at 09:48 AM revealed LVN D administered medication through the feeding tube. LVN D got the following medications ready: Vitamin C 500 mg 1 tablet. <BR/>Vitamin B-12 1000 mcg 1 tablet, Ferrous Sulfate 325 mg 1 tablet, Folic acid 800 mcg 1 tablet, Lactulose solution 30 cc, Furosemide 20 mg 1 tablet, Ibuprofen 800 mg 1 tablet. <BR/>Staff crushed medication and mixed with water. The resident feeding tube was infusing, and she paused the feeding tube and then disconnected the feeding tube from the resident and flushed with 20cc of water. Administered medication and flushed after. <BR/>In an interview on 11/06/23 at 10:15 AM with LVN D she stated regarding checking resident residual, she stated she forgot, and she was supposed to check to make sure the resident did not have more than the recommended amount which could lead to aspiration or vomiting. LVN D stated there were parameters that the staff were supposed to follow when checking for residual, and if the resident had more than the recommended amount, she was supposed to inform the primary care provider and hold any infusion. <BR/>In an interview on 11/07/23 at 03:20 PM with the DON she stated LVN D was supposed to check the resident residual before medication administration to make sure the resident was not being overfed which could lead to aspiration and vomiting. The DON stated the nurse was in-serviced on medication administration. <BR/>Record reviewed of the in-service provided on medication administration, <BR/>Record review of the facility policy dated 01/25/13 and titled Enteral Medication Administration reflected, Check the placement of the tube by aspiration of contents or auscultation. Elevate the resident per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11%, based on three out of 27 opportunities, which involved 2 of 5 residents (Resident #7 and Resident #75) reviewed for medication errors.<BR/>1. <BR/>LVN D failed to administer medications as ordered to Resident #7 by administering Vitamin B-12 1000 mcg instead of Vitamin B-12 500 mg and administered Folic acid 800 mcg instead of 1mg. <BR/>2. <BR/> LVN D failed to administer medication as ordered to Resident #75 by administering Levemir 18 units instead of Lantus 18 units. <BR/>These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain.<BR/>Findings include:<BR/>1. Record review of Resident #75's face sheet, dated 07/07/23, reflected a 71-years old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #75 had diagnoses which included: reduced mobility, muscle waiting, depression, anxiety, and morbid obesity. <BR/>Record review of Resident #75's significant change MDS assessment, dated 08/04/23, reflected Resident #75 had a BIMS score of 15 indicating no impairment and required extensive assistance with activities of daily living. <BR/>Record review of Resident #75's November 2023 MAR reflected Resident #75's had the following medication scheduled for 8:00 AM. Insulin Glargine 18 units, Metoprolol ER 5mg, Sertraline 80 mg, Letrozole 2.5 mg, Gabapentin 100 mg, Cardizem 120 mg, MiraLAX 17 gm, Vitamin C 250mg, Eliquis 5 mg and Vilanterol Inhalation. <BR/>An observation on 11/06/23 at 09:35 AM revealed LVN D administered the following medications to Resident #75; Levemir - 18 units - administered to the left deltoid, Metoprolol 50 mg ER 1 tablet, Sertraline 80 mg 1 tablet, Letrozole 2.5 mg 1 tablet, Gabapentin 100 mg 1 tablet, Cardizem 120 mg 1 tablet, MiraLAX 17 gm, Docusate 100 mg 1 tablet, Vitamin C 250 mg 1 tablet, Eliquis 5 mg 1 tablet, Ferrous Sulfates 325 mg 1 tablet, Vilanterol Inhalation <BR/>2. Record review of Resident #7's face sheet, dated 07/07/23, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Gastrostomy status (an opening in the stomach at the abdominal wall made surgically to introduce food), dysphasia (speech disorder), and cerebral palsy (a group of disorders that affect movement, muscle tone, balance, and posture).<BR/>Record review of Resident #7's annual MDS Assessment, dated 05/03/23, reflected Resident #7 had a BIMS score which was blank, which indicated severe cognitive impairment. Resident #7 required extensive to total assistance with ADLs with two persons assist. Further review reflected Resident #7 had a feeding tube.<BR/>Record review of Resident #7's medication administration record reflected Resident #7 had the following mediations scheduled at 8 am; Vitamin C 500 mg, Vitamin B-12 1000 mcg, Ferrous sulfate 325 mg, Folic acid 800 mcg, lactulose solution 30 cc, furosemide 20 mg and Ibuprofen 800 mg. <BR/>Observation on 11/06/23 at 09:48 AM revealed LVN D administered the following medications to Resident #7 via the feeding tube; Vitamin C 500 mg 1 tablet, Vitamin B-12 1000mcg 1 tablet, Ferrous Sulfate 325 mg 1tablet, Folic acid 800 mcg 1 tablet, Lactulose solution 30cc, Furosemide 20 mg 1 tablet and Ibuprofen 800 mg 1 tablet <BR/>In an interview on 11/06/23 at 02:57 PM with LVN D, regarding medication administration she stated she was supposed to follow the five rights of medication administration: patient, dose, medication, route, and time. LVN D stated she realized she administered the wrong insulin to Resident # 75, so she called the pharmacy and ordered the right medication (Lantus). LVN D stated she was supposed to administer Lantus to Resident #75 instead she administered Levemir. LVN D stated both were long-acting insulin. Regarding Resident #7 physician order review the resident was supposed to take Vitamin B-12 500 mcg and Folic acid 1 mg. LVN D stated she did not realize she had not administered the correct dose for Vitamin B-12 and Folic acid to Resident #7. LVN D stated administering the wrong dose of medication could lead to adverse health effects and even death. <BR/>In an interview on 11/07/23 at 03:20 PM with the DON she stated staff were supposed to make sure during medication administration they administered the right dose and the right medications. The DON stated the staff were to follow the rights of medication administration to prevent medication error and adverse effects from the wrong medications. The DON stated the Pharmacy consultant completed medication pass with the charge nurses monthly. The facility completed medication administration in-service in August or September.<BR/>Record review of the facility policy, revised on 10/25/17, and titled Medication Administration Procedures reflected, 20. The 10 rights of medication should always be adhered to<BR/>1. Right patient<BR/>2. Right medication<BR/>3. Right dose<BR/>4. Right route<BR/>5. Right time<BR/>6. Right patient education<BR/>7. Right documentation<BR/>8. Right to refuse<BR/>9. Right assessment<BR/>10. Right evaluation<BR/>NOTE: Any deviation from specified and recommended procedures in dispensing or administering medications to the resident requires documented approval by the Quality Assurance Committee and shall be in concurrence with current statutes and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas and smoking safety that also took into account nonsmoking residents for 2 of 2 residents (Resident #11, Resident #81) reviewed for safe smoking.<BR/>The facility failed to develop a policy to address residents signing in and out on a Release of Responsibility for Leave of Absence form to smoke, which included Resident #11 and Resident #81.<BR/>This failure could place residents at risk for injury, burns and an unsafe smoking environment.<BR/>Findings include:<BR/>1. Record review of Resident #81's face sheet dated 11/07/23 indicated Resident #81 was a [AGE] year-old male, with an original admission to the facility on [DATE] and readmitted on [DATE]. Resident #81 had diagnoses which included dementia (group of symptoms affecting memory, thinking and social abilities) alcohol dependence, tobacco use, major depression, and difficulty in walking. <BR/>Record review of Resident #81's annual MDS assessment dated [DATE] indicated Resident #81 was understood and understood others. Resident #81 had no difficulty hearing and had clear speech. Resident #81 had a BIMS score of 15 which indicated intact cognition. Resident #81 required supervision with activities of daily living, and he was independent.<BR/>Review of Resident #81 care plan did not address smoking. <BR/>Observation on 11/05/23 at 09:42 AM revealed residents at the back entrance near the door smoking and there was no supervision from the staff. <BR/>Observation on 11/05/23 at 11:38 AM revealed there were three residents who were in the wheelchair, and they were smoking on the outside of the back entrance. <BR/>Observation and interview on 11/05/23 at 02:08 PM, revealed Resident #81 walking back to his room. He was well groomed, and he was appropriately dressed. In an interview with Resident #81 he stated he was coming back from smoking. Resident #81 stated he could go outside anytime and smoke, there was no set time for smoking. He then pulled the cigarettes and lighter from his chest pocket. Resident #81 stated he kept his lighter and cigarettes on top of the bedside nightstand. Resident #81 stated he was aware the facility was a smoke free facility, and no one had taken the cigarettes from him, and he was not informed he would be discharged due to his smoking. Resident #81 stated he smoked at the entrance of the back entrance door and there was no staff supervision when the residents smoked. <BR/>In an interview with LVN E on 11/05/23 at 11:40 AM, she stated she did not know the residents who were smoking outside because they were from other halls. LVN E stated there were residents in her hall who smoked, there was no scheduled time to smoke, and the residents kept their lighters and cigarettes. LVN E stated there was no resident supervision when they smoked, the residents were supposed to sign out when they went to smoke but they did not. There was no designated staff who was to make sure the residents signed out when they left to go smoke.<BR/>2. Record review of Resident #11's face sheet, dated 11/07/23, indicated Resident #11 was a [AGE] year-old male, with an original admission date of 05/02/22 and readmission on [DATE]. Resident #11 had diagnoses which included type 2 diabetes mellitus (to a group of diseases that affect how the body uses blood sugar (glucose)) need for assistance for personal care, muscle weakness and pain. <BR/>Record review of Resident #11's annual MDS assessment dated [DATE] indicated Resident #11 was understood and understood others. Resident #81 had no difficulty hearing and had clear speech. Resident #11 had a BIMS score of 14 which indicated intact cognition. Resident #11 required assistance with activities of daily living. <BR/>Observation and interview on 11/06/23 at 03:42 PM with Resident #11 revealed he was resting in bed. He was well groomed, and he was appropriately dressed. Resident #11 stated he smoked couple of times per day whenever he felt like. He stated there was no set time for smoking. Resident #11 stated he kept his lighter and cigarettes in his bedside nightstand, and when he opened the drawer the lighter and pack of cigarettes were inside. <BR/>In an interview on 11/05/23 at 02:57 with the DON she stated she had worked two years in the facility. The facility had been non-smoking since before she started working two years ago. The DON stated during the admission the residents were informed the facility was non-smoking. If the resident came to the facility, then they chose not to smoke and if they were found smoking in the facility the family was informed to pick up the cigarettes. If the resident was found to have smoked paraphernalia or smoking, they were educated an asked for their smoking items, if they refused the family was asked to come get the items. The DON observed Residents #81 & #11 smoke. The DON stated Resident #81 gave her his cigarettes and the lighter around August 2023. The DON revealed social services and nursing followed up to ensure the residents remained free of smoking. The DON stated if any resident wanted to smoke, they had to go to the boundary at the back side of the facility. The DON stated they had 19 residents who smoked. The DON stated the facility did not have a smoking policy because it was a non-smoking facility. The DON revealed the residents were offered the nicotine patch upon admission to stop smoking. The DON stated when the residents who smoked wanted to smoke, they had to sign out and sign back in, when the residents signed out the facility was not liable, she further stated any resident who went outside without signing out the nurse was to get the book and have the resident sign. The DON revealed no incidents related to smoking had been reported. The DON revealed a resident that was continually non-complainant would be offered a discharge notice but none of the residents had been given the discharge notice. <BR/>In an interview on 11/05/23 at 5:08 PM with Administrator, he stated the facility was a non-smoking facility. The Administrator revealed during admission the hospital case manager informed the resident at the hospital the facility was a non-smoking place. The Administrator stated the previous administrator had the residents who smoked go to the front of the property street where it is was dangerous, so the facility set a section in the back of the facility where they were to smoke. The Administrator stated there were 19 smokers, who had their own cigarettes, and the facility did not keep the residents' cigarettes. The Administrator revealed the residents were educated of risks of smoking but did not have records for the teaching, the Administrator stated the facility was a non-smoking facility and if a resident wanted to step out of the facility to smoke, they were to sign out and they were on their own. The Administrator revealed there was no designated time or location for a resident to go outside. The Administrator revealed his expectation was to fix the supervision during smoking. He stated there was no smoking policy although there were residents in the facility who smoked because the facility was a smoke free facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers. <BR/>The facility failed to appropriately identify the Resident #1's pressure ulcers, obtain and provide appropriate treatment, monitor the wounds, and provide interventions to prevent further deterioration of the wounds. Resident #1 was hospitalized and had sugery for osteomyelitis (bacterial infection in the bone) of the bone/joint of the right hip. <BR/>This failure could place residents with wounds at an increased and unnecessary risk of complications such as pain, acquiring new pressure ulcers, worsening of existing pressure ulcers and infection. <BR/>Findings include: <BR/>Review of Resident #1's face sheet dated 9/28/2023 revealed a [AGE] year-old female admitted to the facility 08/24/2012 with a readmission on [DATE]. Resident was discharged to acute care facility on 09/19/2023 at 1:38 PM. Resident #1's diagnoses included: a disease present at birth causing chronic joint pain and limited mobility; and generalized muscle weakness. <BR/>Review of hospital document: Wound Care Consultation dated 09/20/2023 at 6:07 PM, HWCP wrote Resident #1 was admitted to the hospital for altered mental status and worsening right hip wound. Resident #1 was found to have bilateral hip wounds. The family was unaware of how long she had the hip wounds. HWCP wrote large extensive left hip decubitus (injury to the skin caused by pressure) ulcer (open sore) with eschar (dead tissue) loosened at the edges with slough (yellowish/white tissue on the wound bed) and scant serosanguineous (thin pinkish) drainage. Right hip decubitus ulcer with fair quality viable tissue, slough, with loosening eschar with bone palpable (felt w fingers) at the base. There is moderate serosanguineous drainage. Very faint redness noted in the surrounding skin, no foul odor noted. <BR/>Review of Hospital document - Operative/Procedure Notes dated 09/28/2023 Resident #1 had surgery on 9/26/2023 related to osteomyelitis (bacterial infection in the bone) of the bone/joint of the right hip. <BR/>Review of Resident #1's significant change MDS dated [DATE] Resident #1 was cognitively intact as evidence by a BIMS score of 15, no behavioral issues identified. Resident #1 was dependent on facility staff for all ADL care, bathing and required the assistance of 2 people for mobility and transfers. Resident #1 required the assistance of 1 person for dressing, eating, toilet use and personal hygiene. Resident #1 had a tube in her bladder which drained urine into a bag and had bowel incontinence. Resident #1 developed 1 stage 4 (loss of tissue with exposed bone or muscle caused by pressure to a bony region) pressure ulcer on the left elbow.<BR/>Review of Resident #1's care plan, reflected as of 7/31/2023 Resident #1 had an abscess to the right hip, goals of care was that resident would remain on palliative (non-aggressive) wound care. Interventions included assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. <BR/>Review of Resident #1's progress notes revealed an entry dated 7/31/2023 at 1:10 PM WCN A identified Resident #1 had developed an abscess with multiple heads to the right hip. WCN A wrote wound care is palliative wound due to resident overall significantly declining condition, non-compliance and significant weight loss. Resident will continue to have skin breakdown due to her condition physician notified. <BR/>Review of Resident #1's Order Summary Report Printed 9/27/2023 reflected: as of 7/31/2023 cleanse right hip wound with wound cleanser, pat dry apply Dakin (wound cleanser) half strength solution soaked in gauze then cover with protective dressing change every Monday-Wednesday-Friday, every day shift (added 8/2/2023) and as needed. <BR/>Review of Resident #1's Wound Administration Record dated August 2023 revealed Resident #1 refused treatment to the right hip 8/23/2023, otherwise it was documented as provided as prescribed. <BR/>Review of Resident #1's Wound Administration Record dated September 2023 revealed Resident #1's treatment to the right hip was documented as provided as prescribed. <BR/>Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 8/24/2023 WCN A noted in the section marked additional information .will continue with palliative wound care to .right hip wound. No documentation found in the EHR regarding the condition/description of the wound on the right hip. <BR/>Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 8/30/2023 WCN A noted in the section marked other Resident is declining significantly, continue with hospice care. Refusing dressing change per order. refused to change her hip dressing on 8/30/2023. No documentation found in the EHR regarding the condition/description of the wounds on the hips. <BR/>Review of Resident #1's weekly skin assessment dated [DATE] completed by WCN A revealed under other skin findings - .and right hip. <BR/>Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 9/07/2023 WCN A noted in the section marked other Resident on hospice with palliative care. Not eating much. Resident continue to non-compliance with turning and repositioning. Resident hip wound will continue with Dakin half strength solution soak. Resident is high risk for skin breakdown due to her declining condition and non-compliance with turning and repositioning. No documentation found in the EHR regarding the condition/description of the wounds on the hips. <BR/>Review of Resident #1's weekly ulcer assessment of the Stage 4 wound on the left elbow, dated 9/14/2023 WCN A noted in the section marked other, Resident continue to decline and refusing wound care more noted. Continue to refuse for turning and reposition per protocol. Continue to have skin breakdown. No documentation found the EHR regarding the condition/description of the wounds on the hips. <BR/>Review of Resident #1's progress notes revealed, an entry dated 09/19/2023 at 4:14 PM, WCN A wrote, Resident dressing change was done, Resident continue to have bilateral hip wound . Resident is declining with significantly with unavoidable wounds. Family had a meeting with hospice nurse and ultimately sent Resident #1 to the hospital. No documentation found in the EHR regarding the condition/description of the wounds on both hips. <BR/>Review of an addendum to 9/19/2023 progress notes dated 09/27/2023, WCN A described Resident #1's right hip as showing evidence of skin failure; within the wound bed was black eschar with some drainage with exposed bone. The left hip was described as having a deep tissue injury noted size about 5.2x6.2cm skin intact, surrounding skin normal, irregular edges and no drainage. This injury was not documented in the EHR prior to the day of discharge 9/19/2023. <BR/>In an interview on 09/26/2023 at 2:43 PM, WCN A stated Resident #1 was non-compliant regarding her care. Resident #1 was known to not turn, refuse bed baths and refused dressing changes. Resident #1 has lost weight and developed unavoidable pressure sores in recent months. Resident was placed on hospice 8/22/2023 for pain management and remained a full code. The facility was to provide wound care. <BR/>In an interview on 09/27/2023 at 10:59 AM, FM stated they knew Resident #1 had wounds on her legs and had no knowledge of wounds on her hips. When having conversations with the facility, FM thought the facility was talking about the chronic wounds on Resident #1's legs. <BR/>In an interview on 09/27/2023 at 4:33 PM, the DON reviewed Resident #1's EHR and found no weekly ulcer/wound assessment specific to the hips. On 9/19/2023 Resident #1 was described as having skin failure on the right hip the affected area was measured by WCN A as 8x9.6cm no other description was provided. The DON stated that given the size of the injury she would have expected a description of what was measured and what was observed. This information would allow for the proper care and treatment of the wound. <BR/>In an interview on 09/28/2023 at 11:22 AM with WCN A, believed the missing documentation was the result of computer glitches. WCN stated on 8/29/2023 time unknown, Resident #1 was noted to have an abscess with a small opening on the right hip, the surrounding tissue was discolored. WCN A measured the discolored area, measurements were not found documented in the EHR corresponding to the date of 8/29/2023. <BR/>In an interview on 09/28/2023 at 12:52 PM, PP stated that Resident #1 had been in declining health for the past couple of months. PP was aware of an abscess on the right hip; was not certain if the abscess had opened prior to Resident #1's discharge to the hospital. PP did not recall knowing that the Right hip had an open sore that measured 8x9.6cm with exposed bone. PP was not aware that the left hip had a deep tissue injury that measured 5.2x6.2cm with intact skin. <BR/>In an interview on 09/28/2023 at 2:30 PM, the Adm stated he was not aware that Resident #1 had developed wounds on the hips. The DON would provide the expectations for documentation. <BR/>In an interview on 10/11/2023 at 11:33 AM, LVN C stated Resident #1's health was in decline for the past several months. Resident #1 was resistant to care, showers and turning r/t chronic pain caused by the disease present since birth. Resident #1 developed a poor appetite and would drink small amounts of fluids. LVN C stated that WC provided the treatments for Resident #1's wounds. LVN C had not recently visualized Resident #1's right hip because it usually had a dressing on it. <BR/>In an interview on 10/11/2023 at 11:51 AM, WCN B stated she provided wound care to Resident #1 on Monday 9/18/2023 and it was checked off in the TAR. WCN B said there was no need to document anything as checking off on the TAR was sufficient to indicate that wound care was performed. WNC B described the right hip as having an open area about the size of her palm, the wound bed was red, with yellowish white and dead tissue. WCN B did not recall seeing exposed bone. WCN B described Residents #1 decline in health in recent months and her refusal to reposition and eat, which would impact her skin. <BR/>In an interview on 10/11/2023 at 12:17 PM, WCN A stated that skin failure occurs when a person is dying they stop eating, depriving cells of nourishment, circulation is diverted to the major organs. Resident #1 was eating and drinking very little and would refuse to reposition all contributed to an unavoidable deterioration of her skin. WCN A said when a resident has all interventions i.e. air mattress, protein supplements, vitamins, repositioning in place and adequate nutrition and hydration and the skin breaks down that's skin failure. WCN A did not refer to the wound on Resident #1's right hip as a pressure related injury. <BR/>In an interview on 10/11/2023 at 12:51 PM, DON stated that Resident #1 had an open wound on the right hip that was being treated by WC. DON described skin failure as the result of not eating, drinking or moving. Not getting the nutrients and staying in one position led to decreased circulation, the tissue/skin begins to die in a short period of time depending on the overall health of the person. <BR/>In an interview on 10/11/2023 at 1:07 PM, ADM stated that on the day Resident #1 was discharged to the hospital, the family was present during wound care and verbalized no questions or concerns regarding the wound on the right hip. ADM stated the family had been present at other times during WC and had not verbalized concerns or questions. <BR/>In an interview on 10/11/1023 at 6:04 PM, PP stated that he met with WCN A every week and he was not informed of any concerns or changes in the wound on Resident #1's right hip. PP described the wound was stable (measurements unchanged) and the current treatment was appropriate. PP described Resident #1 was experiencing a decline in health, she was known to refuse repositioning, eating and drinking resulting in poor healing of wounds including the right hip. PP stated that he had not visualized the wound himself, his decisions were based on the information provided to him from WCN A. <BR/>Review of facility policy, undated Wound Treatment and Management, #5 treatment decisions will be based on: <BR/>a. Etiology of the wound b. Characteristics of the wound

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <BR/>Based on observation, interview and record review the facilty failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care.<BR/>The facility failed to ensure Resident #3 was provided oxygen as prescribed by the physician.<BR/>This failure could place residents at risk for not reciving medication/ biologicals as ordered<BR/>Findings included:<BR/>Review of Resident #3's face sheet dated 6/5/23 revealed an 80 year- old female admitted to the facility on [DATE] with diagnoses of acute kidney failure( a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days), congestive heart failure( a long-term condition tht happens when your heart can't pump blood well enough to give your body a normal supply) protein-calorie malnutrion (status in which reduced availability of nutrients leads to changes in body). Resident #3 was re-admitted to the facility on [DATE].<BR/> Review of Resident #3's physician order revealed oxygen at 2-4 liters per minutes continious via nasal cannula per concentrator or cylinder to keep oxygen saturation level at or above 93%.<BR/>Review of Resident #3's care plan dated 4/7/23 revealed the resident recieved oxygen therapy.<BR/>Observation and interview on 6/5/23 beginning at 11:25 AM revealed Resident #3 had an oxygen tank in her room that was beeping indicating an error. Resident #3 did not have the oxygen cannula in her nose. Attempt to interview Resident #3 was unsuccessful due to the resident being confused. The resident was not able to answer any questions. The Surveyor pushed Resident #3's call light at 11:27 AM to recieve assistance with the error code on the oxygen machine. A CNA arrvied at 11:32AM and stated she was not sure what was wrong with the oxygen machine stating she had only worked in the facility for two days. The CNA stated she would get a nurse and did not put the oxygen cannula on the Resident #3's nose. The MDS Coordinator arrived to the room at 11:30AM and stated she was not sure if the resident had continuous oxygen and she was not sure what the error meant on the oxygen machine and that she would get a nurse. The MDS coordinator did not put the oxygen cannula on the resident nose. LVN A arrived at 12:57 PM and stated she was not sure what the error message on the oxygen machine meant and stated Resident #3 had oxygen as needed and the LVN proceeded to turn off the oxygen machine.<BR/>Interview on 6/5/23 at 12:00PM with LVN A revealed Resident #3 was on oxygen as needed which was why she turned the oxygen machine off. Resident #3's oxygen level was checked and determined to be at 96%. LVN A turned off the oxygen machine and left Resident #3's room.<BR/>In a follwo up interview with LVN A on 6/5/23 at 1:30PM LVNA stated she was in the process of trying to get an order for Resident #3's oxygen to be as needed instead of continous. LVN A stated Resident #3 often takes off her oxygen mask which was why she did not have it own. LVN A stated she later went back into Resident #3's room and turned the oxygen machine on.<BR/>Interview on 6/5/23 at 1:45PM with the Director of Nursing revealed Resident #3 was on oxygen continous when she was admitted however the resident went out to the hospital and came back on 6/2/23 with a new order. The Director of Nursing stated the alert on the oxygen machine meant the filter needed to be changed or a new machine was needed. The Director of Nursing stated it was the responsiblity of the LVN's to ensure residents recived oxygen according to their physcian order. The Director of Nursing stated the risk of residents not receiving oxygen as prescribed would be that the resident could have respiratory distress.<BR/>Review of the facility policy medication administration procedure undated revealed, Any deviation from specified and recommended procedures in dispensing or administering medication to the resident requires documented approved by the quality assuance committe and shall be in concurrence with current statuses and regulations.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for appointments. <BR/>The facility failed to schedule an appointment with the lymphedema clinic for Resident #1 per physician's orders to address her reoccurring cellulitis. <BR/>The failure placed residents at risk of not receiving continuity of care. <BR/>Findings included:<BR/>Review of Resident #1's MDS dated [DATE] revealed the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included heart failure, cellulitis (bacterial skin infection), cognitive communication deficit, and pain. <BR/>Review of Resident #1's care plan initiated on 04/07/23 revealed the resident was on Lasix therapy related to edema (swelling due to excess fluid accumulation in the body tissues). The care plan approaches included reporting any increased swelling of her legs, arms, or face to the charge nurse and the physician. <BR/>Review of Resident #1's April 2023 Order Summary Report revealed the following:<BR/>Referral: Lymphedema clinic. Reason RUE Chronic lymphedemas [a condition of localized swelling] s/p Mastectomy with an order date of 02/23/23. <BR/>Observation and interview on 04/07/23 at 11:15 AM with Resident #1 revealed she in was in bed watching television. The resident stated her right arm was hurting and her fingers appeared to have some swelling. Resident #1 said this was constant for about 10 years after her having her breast removed. <BR/>Interview on 04/07/23 at 3:02 PM with the ADON revealed orders for resident appointments were done by the Social Worker. <BR/>Interview on 04/07/23 at 3:08 PM with the Social Worker revealed she was notified of referrals either through meetings or directly by a charge nurse. The Social Worker stated she did not know there was a lymphedema clinic referral for Resident #1. The Social Worker stated she could have possibly missed it, and an appointment had not been made. She stated the risks of not acting upon referrals included resident health conditions worsening. She stated she would follow-up and schedule an appointment for Resident #1 at the lymphedema clinic. <BR/>Interview on 04/07/23 at 3:26 PM with the DON revealed she was told, but was not able to recall by who, Resident #1's lymphedema referral was to be used in the case they needed it. She stated at the time it was ordered, the resident was not having any problems. The DON said the Social Worker was responsible for making appointments for referrals, and the risk of not making appointments included resident health conditions worsening. <BR/>Interview on 04/07/23 at 2:32 PM with the Nurse Practitioner revealed Resident #1 was having reoccurring cellulitis and swelling in her right arm related to her mastectomy. She stated the resident reported having the cellulitis for years, while she lived at home. The Nurse Practitioner stated they treated the cellulitis in February with antibiotics, and she stated she recommended a lymphedema clinic referral to help address the issue. The Nurse Practitioner stated she saw Resident #1 the day prior, 04/06/23, and the resident had some swelling to her right elbow, but it was not too bad. She also said she would be following up with the ADON to see about the referral she had recommended in February 2023. <BR/>Review of the facility's policy titled Appointments dated 2003 revealed the following:<BR/>The facility will assist with outside facility resident appointments to ensure the resident attends any scheduled appointment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including the procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications and pharmacy services. <BR/>The facility failed to take Resident #1's blood pressure and administer her medication in accordance with the physician orders. Resident #1 was administered Propranolol (a beta blocker medication that relaxes blood vessels in the body is used to treat a variety of conditions including high blood pressure) three times a day from 12/01/24 through 01/18/25. The medication was only to be given if her blood pressure was over 110/60. However, there was no documented evidence to indicate her blood pressure was taken in her clinical record to validate the medication needed to be given and did not need to be held. <BR/>This failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and potential for decreased health status, including low and high blood pressure, falls, disorientation and physical discomfort. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/25 reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included hypertension (abnormally high blood pressure that is not the result of a medical condition), Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions), dementia with mood disturbance (a decline in cognitive function with behavioral disturbances due to the progressive deterioration of brain cells), and repeated falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed her BIMS score was 05, which indicated severe cognitive impairment. She had unclear speech and sometimes understood others. Resident #1 had no signs or symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no verbal or physically aggressive behaviors, and no rejection of care. Resident #1 had no range of motion of issues and used a wheelchair for mobility and she required substantial/maximum assistance for activities of daily living. <BR/>Record review of Resident #1's care plan dated 06/27/24 and last revised on 01/17/25 reflected she was at risk for falls due to her Huntington's diagnosis and had an unwitnessed fall on 01/13/25; however, there was no focus area reflected for her hypertension or related interventions. <BR/>Record review of Resident #1's January 2025 Physician's Orders reflected she was prescribed the beta blocker Propranolol 0.5mg three times a day for a diagnosis of hypertension (Start Date 06/27/24-open ended). The order also reflected, Hold for SBP&lt;110 and DBP &lt;60.<BR/>Record review of Resident #1's December 2024 and January 2025 MAR reflected she was administered the medication Propranolol every day she was at the facility from 12/01/24 through 01/18/25 with the exception of twice on 12/19/24 and once on the 12/20/24. The MAR also indicated under the name of the medication that it had parameters to be held if the blood pressure was 110/60.<BR/>Record review of Resident #1's vital records on the e-chart documented under the Vitals Tab reflected blood pressure readings only on 12/06/24, 12/13/24, 12/20/24, and 12/27/24. There were no blood pressure readings three times a day for Resident #1 from 01/01/25 through 01/18/25.<BR/>An interview with ADON B on 01/22/25 at 2:51 PM reflected she was in charge of overseeing the secured unit where Resident #1 lived, but all resident blood pressure audits were done by the other two ADONs. ADON B stated if there was an order for blood pressure to be taken prior to giving a medication, then the blood pressure should be taken. If it was not taken or if a resident refused or was moving too much to get an accurate reading, then the staff would need to notify the charge nurse so it could be documented. ADON B stated taking a resident's blood pressure was tied to their vitals parameters and if a medication for hypertension was given and the resident's blood pressure was already low, it could cause the resident to become unresponsive or sustain a fall. ADON B stated the blood pressure entry should be documented on the MAR with the medication. She stated when a MAR was being generated, the person generating it was responsible for ensuring the vitals parameter box was checked in order for it to show up and be placed on the MAR for staff to enter blood pressure readings. <BR/>An interview with MA D on 01/23/25 at 11:52 AM reflected she worked with Resident #1 the morning of 01/18/25 and worked a double shift from 7AM to 11PM. MA D stated she knew what the medication Propranolol was used for, and she gave it to Resident #1 routinely and crushed it into applesauce to feed it to her. MA D stated she took Resident #1's blood pressure reading each time before she gave the medication but there was not a place on the MAR to document it as the nursing staff had not added it to the document to record it. MA D stated she always assessed Resident #1 before giving her medications, which included taking her blood pressure. MA D stated she normally wrote those readings down on paper and kept it during her shift in case anyone, such as the MD or the NP came to the facility, and wanted to know what they were for the resident. MA D stated, But at the end of the day, I usually destroy it, but when I am work, I write it in case I need to prove it (taken the resident's blood pressure). MA D stated taking the residents' blood pressure was important because if the blood pressure was too low and a medication was given when it was supposed to be held, the resident might go into crisis, like a seizure, or if the blood pressure was too high, then steps needed to be taken to lower it. <BR/>An interview with the DON on 01/23/25 at 1:57 PM reflected that after state investigator intervention, the nursing management team went back and audited the resident's MAR and ensured all the MARs had corresponding vitals parameters (including blood pressure), if indicated, and in-serviced staff. The DON stated that even if the blood pressure was not on the MAR when it was generated, the medication aides as well as the nurses were capable of going in and revising the MAR and adding it . <BR/>Record review of the facility's policy titled, Medication Administration Procedures dated 2003 reflected, .13.When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a reasonable accommodation of resident needs and preferences for two residents (Resident #263 and Resident #139).<BR/>The facility failed to repair resident #139's call light in her room<BR/>The facility failed to repair resident #263's call light in her room.<BR/>These failures could place residents at risk for an unsafe environment and a reduced quality of life, due to call lights not being operational.<BR/>Findings Included:<BR/>Observation of Resident #139's call light on 09/14/22 at 8:15 a.m. revealed that the red button on the call button cord was missing preventing resident from calling for assistance when needed. The resident was non-verbal and was observed calling out saying ([NAME], [NAME], [NAME]). <BR/>Record Review of Resident #139's face sheet dated 09/14/22 revealed she was admitted on [DATE] with the following diagnosis: Unspecified Dementia, Anemia, Type 2 Diabetes Mellitus without complications, Anxiety and Schizophrenia. wheelchair bound, with bilateral hand tremors and generalized weakness cause resident to need assistance with all ADLs. Resident's call light is within reach and resident was educated to use the call light as needed for assistance. <BR/>Observation on 09/14/22 at 8:15 a.m. revealed Resident #263 was not interviewable and was calling out saying ([NAME], [NAME], [NAME]). His call light was located on his pillow within reach. A test of the resident call light revealed that it was not working. <BR/>Interview with RN on 09/14/22 at 8:20 a.m. revealed that she was not aware that the call light in resident #263's and 139's room was missing the red button and not working. <BR/>Record Review of Resident #263's face sheet dated 09/14/22 revealed he was a [AGE] year-old male that was admitted on [DATE] with the following diagnosis: Metabolic Encephalopathy, Presence of Cardia Pacemaker, Pain, Unspecified, Vascular Dementia., Anemia, Type 2 Diabetes Mellitus without complications, Anxiety and Chronic Kidney Disease. <BR/>Record Review of Resident #263's Minimum Data Stats (MDS) dated [DATE], revealed that the resident was identified as having memory problems, and resident was dependent on staff for transfers, eating, incontinence care, bathing, and day-to-day care. <BR/>Record Review of Resident #263's Care Plan dated 09/13/22, revealed Resident has an ADL self-care performance deficit related to Dementia and Limited Mobility. The following interventions were listed for resident, include the resident requires extensive assistance of two-person physical assistance from staff to move between surfaces as necessary. Encourage the resident to use bell to call for assistance and praise all efforts at self-care. There was no mention of having the call light within reach of the resident. <BR/>An Interview with RN F on 09/14/22 at 8:20 a.m., revealed that she was not aware that the call light in Resident #263's and Resident 139's room were missing the red button and not working. <BR/>An interview with LPN E, the second nurse working with Resident #139 on 09/14/22 at 8:23 a.m. LPN E stated that she was not notified of the resident's lights not working and was missing the red button. She stated that she would reach out to the maintenance tech on the hall to get assistance.<BR/>Interview with the Maintenance Director on 09/14/22 at 8:25 a.m. revealed that he was not notified of the non-working call lights. He stated that it was the staff working on the unit's responsibility to notify maintenance of environment devices that were not working or had been altered. He stated that he did not need to write the room numbers and call light information down, as he was headed to get the equipment to repair at this moment. <BR/>Record review of Resident #139's progress notes on 09/14/22 at 10:00 a.m. revealed a skilled nursing note by RN E on 08/22/22 at 4:36 p.m. reading Ox1, forgetful. Wheelchair bound, bilateral hand tremors, and generalized weakness cause resident to need assistance with all ADLs. Resident's call light is within reach and resident was educated to use the call light as needed for assistance.<BR/>Record review of the maintenance log on 09/15/22 at 9:00 am, located at the nursing station revealed that the staff had not submitted a work order request for maintenance to repair/replace non-working call lights for the rooms referenced.<BR/>In the exit conference on 09/15/22 at 6:25 PM, the Administrator and DON stated the facility did not have a policy regarding maintenance repairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 5 of 9 residents (Residents #1, #2, #7, #8, #9) reviewed for environment. <BR/>The facility failed to ensure Residents #1, #2, #7, #8, and #9 had hot water for washing and bathing in their rooms.<BR/>This failure affected residents by placing them at risk for a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes.<BR/>In an observation of Resident #1's bathroom on 1-20-2024 at 4:40PM, it was discovered that Resident #1 did not have hot water in her bathroom. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that there wasn't hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of assistance with ADL. <BR/>In an observation of Resident #2's bathroom, on 1-20-2024, at 5:00 PM, it was confirmed that Resident #2 had no hot water in her bathroom. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia, and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis. <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was conveyed that Resident's bathroom hasn't had hot water for weeks. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>In an observation of Resident #7's bathroom, on 1-20-2024, at 5:20 PM, it was confirmed Resident #7's bathroom was without hot water. <BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 has a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8 stated his room hasn't had hot water for over a week. <BR/>In an observation of Resident #8's bathroom, on 1-20-2024, at 5:20PM, it was revealed that Resident #8 did not have hot water in his bathroom. <BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 has a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism, unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room hasn't had hot water for over a week. <BR/>In an observation of Resident #9's bathroom, on 1-20-2024 at 6:10 PM, it was confirmed that Resident #9 had no hot water in his bathroom. <BR/>In an interview with the Director of Maintenance by phone, it was revealed he is offsite up north. The Director of Maintenance said there was hot water in the lines, but he thinks the mixing valve is defective, which could be causing the water, in the 300 area, to not be hot in the resident's rooms. However, he was not sure if that was the problem. The Director of Maintenance said they were waiting on a part to come in Monday to see if that fixes the problem. The Director of Maintenance stated that the water temperature has dropped below 102 degrees Fahrenheit, in the line, but not over 2 weeks. The Director of Maintenance would not say how long the water temperature has been a problem. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was revealed that his expectation was that residents have hot water in their bathrooms. The Administrator stated that one of their tankless water heaters had to be replaced and the control valve that adjusts the heat wasn't working. The Administrator stated that a part has been ordered and should be at the facility next week. The Administrator said was the Director of Maintenance's responsibility to ensure residents have hot water in their bathrooms. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was learned that her expectation was that residents be taken to units that do have hot water to use. The DON stated that when residents do not have hot water in their restrooms, it could be an infection control issue. The DON said the facility had a problem with hot water in the 300-room domain. The DON stated it was everyone's responsibility to make sure residents have hot water and report it when residents don't. <BR/>Record Review of the facility's undated Hot Water Systems Policy stated the hot water system will be checked daily to include shower temperatures. The water temperatures should be maintained at 100 degrees Fahrenheit minimum .<BR/>13.Temperature readings will be recorded on the water temperature log. <BR/>14. <BR/>The hot water tanks should be adjusted accordingly with readings that are too high or too low. Adjustments will be noted on the water temperature log.<BR/>15. <BR/>After adjustments are made, the temperature must be rechecked within thirty minutes of the adjustment. If the water continues to be too hot or too cold, the Administrator should be notified immediately.<BR/>16. <BR/>The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are complete.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure that the food items in the refrigerator were dated, labeled, and sealed appropriately. <BR/>These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. <BR/>Observation on 09/13/2022 at 9:30 a.m. during the initial tour of the small kitchen revealed Food items not dated: 1 undated bread rack that stored facility supply of bread. Further observation revealed one staff personal backpack sitting on bread rack with bread. Two blue Safe Ice Scoop caddies in the small kitchen near entrance door and over the dishwasher contained dead roaches and brown specs and particles of roach feces. <BR/>Upon observation of the small kitchen #1's Dairy Refrigerator A foul odor was detected reminiscent of spoiled foods/dairy, with a brown sticky residue noted to be spilled and dried up around the base of refrigerator.<BR/>Observation and interview with the DM on 09/13/22 AT 9:30 AM of Refrigerator located off from the main kitchen revealed 3 trays of undated thickened liquids, 3 medium size boxes of corn, undated, on shelf defrosting. DM stated that items quality could diminish in the freezer if left unsealed.<BR/>Additional observation conducted with the DM revealed the facility's freezer contained opened, unsealed, undated/unlabeled perishable foods including 1 package of unboxed, undated open meatballs, and an observation of meatballs that had spilled out of the clear package on to the floor and shelves below. 1 open package of chicken patties and 1 open box of hamburger patties not dated. 1 chicken patty on the floor of freezer unpackaged with other spilled particles of crumbs and food.1 box of corn with the top and bag opened and not sealed. 5 boxes of corn on the shelf to the left undated.<BR/>Observation of refrigerator #3 with the DM on 09/13/2022 at 9:38 a.m. revealed undated and labeled foods ,1 cart with approximately 3 rows of desserts were observed undated and labeled and 1 cart of dessert pie uncovered in the kitchen area.<BR/>Observation on 09/13/2022 at 9:45 a.m. of the cook prep and steam table in the main kitchen revealed 1 large staff peach purse and coffee mug under steam table with kitchen prep tools for serving and trays. 1 metal coffee mug placed on top tray of steam table.<BR/>Observation of 09/13/2022 at 9:48 a.m. the handwashing sink in the kitchen revealed paper towel not working and no additional towels for staff to dry hands. <BR/>In an interview the DM on 09/13/2022 at 9:45 a.m. revealed that DM stated that housekeeping routinely brings paper towels to access until dispenser was repaired, and that paper towels should be available to prevent cross contamination after cleaning your hands. DM said that housekeeping had not brought paper towels yet. He stated that he did not contact housekeeping to request paper towels. He stated that it was important to practice good sanitary practices and that he would go and get paper towels. Upon returning to the kitchen for lunch temps, there were no paper towels. and the staff were working on their second meal prep for the day.<BR/>Observation on 09/13/2022 at 11:30 a.m. revealed the kitchen staff resealed and dated of the opened items in the freezer instead of discarding due to exposure. Paper towel dispenser still not working no paper-towels to dry hands after handwashing.<BR/>Interview on 09/13/2022 at 10:10 a.m. with DM he stated that the paper towel dispenser was not working and there were no paper towels observed for staff and guest to dry hands after washing. The DM stated that the housekeeping staff were bringing paper towels for the kitchen staff to use to dry their hands, however at the time of the observation there were no paper towels. Upon returning to the kitchen at 11:45 a.m. there were no paper towels observed for handwashing. He stated that he notified the Maintenance Director (MD) verbally that the machine was not working and to come and repair. DM stated that the boxes that were in the refrigerator were defrosting, he did not say why they weren't labeled. He stated that desserts were just made this morning, so they were fresh. At that time kitchen aid was observed washing her hands and sticking her fingers up in the dispenser to pull down paper towels, touching the machine, therefore hands were decontaminated. <BR/>During an interview with the DM on 09/13/2022 at 2:55 p.m. revealed that if staff are not sealing packages, dating, cleaning hands, this could affect the residents health and they could get sick. He stated that if the packages were open he would need to discard, as the food had been exposed and when foods were unsealed and undated the kitchen staff would not be able to determine when the food was delivered, open, or ready to discard timely. <BR/>Interview on 09/13/2022 10: 15 a.m. with Maintenance Director (MD) revealed that he had not been notified that the kitchen paper towel dispenser needed to be repaired, and he stated that he did not receive a work order for repairs. <BR/>Review of maintenance request LOG? on 9/13/2022 upon request revealed no documentation of a work order to be repair paper towels. <BR/>Interview with the [NAME] on 09/13/2022 at 12:00 pm revealed that she did not observe the meatballs that spilled in the freezer, and that she takes the entire box to the prep area and cook. She stated that she did not observed food on the floor of the freezer. She stated that boxes should be dated and sealed appropriately to prevent food being cooked that has been contaminated. <BR/>Observation on 09/14/2022 at 8:25 a.m. on the (TCU) Transitional Care Unit of the facility revealed a kitchenette located adjacent to the nursing station that had a brown liquid splatter of liquid substance under the sink, open flake cereal undated and sealed, and a gallon of orange juice located in the refrigerator uncovered. <BR/>Interview with CNA-V on 09/14/2022 8:35 a.m. revealed that the cereal stored in the kitchenette area was for resident to eat if they were hungry after hours. She stated that the kitchen brings snacks for the residents to eat before leaving the facility at 8:00 p.m.<BR/>Interview with LVN-E on 09/14/2022 8:45 a.m. revealed that she was working on the unit and that the kitchen provided snacks for the residents to eat, and they were in the room behind the nursing station. <BR/>Interview on 09/14/2022 at 9:09 a.m. with Lead Dietary Manager revealed that he had posted a sign on the TCU unit that health care staff must not store food and drinks in the small refrigerator or pantry areas, due to food regulations prior to leaving the Dietary position. He stated that he would remove all the food located in that kitchenette and notify the DON that food should not be kept in the refrigerator and kitchenette area for residents, and the kitchen staff could not monitor and assure residents were receiving food services consistent with facility guidelines for safe and sanitary conditions. <BR/>In an interview with the Senior Dietary corporate manager on 09/14/2022 at 9:30 a.m. he revealed that the food that was observed on the TCU hall undated and unsealed could lead to exposure of bacteria and illness for the residents. He stated that he previously educated the nursing staff and placed signs for food not to be kept in the TCU cabinets and refrigerator, because all foods need to be kept according to the dietary food procedures for preserving the quality and determining the proper storage quality by dating and sealing. He stated that he would be sending a staff from the kitchen down immediately to remove all food and place a sign on the cabinets and personal refrigerator.<BR/>Record review of Facility policy titled Refrigerated Storage, Dated August 1, 2012, and revised 06/01/2013 FSM-IV-007 POLICY: It is the policy of this facility to store, prepare, and serve foods in accordance with federal, state, and local sanitary codes. PROCEDURE: As a variety of foods are stored under refrigeration, it is essential that refrigerator temperatures be low enough to safely keep the most perishable foods. Refrigerator temperatures that are consistently 38&deg;F or below will provide this safety margin. If it is necessary to store fresh and cooked food in the same refrigerator, the cooked foods should be covered, dated, and labeled and stored above the fresh foods. If it is necessary to store fresh and cooked food in the same refrigerator, the cooked foods should be covered, dated, and labeled and stored above the fresh foods. All foods will be properly wrapped and/or stored in sealed containers and dated and labeled, it is the policy of this facility to maintain equipment, work surfaces, walls, and floors in sanitary condition through daily, ongoing procedures. Formal sanitation inspection in the food service department occurs on a frequent basis. Informal sanitation inspections occur daily.<BR/>FOODBORNE ILLNESS Retail Food Protection | FDA.: <BR/>Food code 2017 Professional Standards Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. Epidemiological outbreak data repeatedly identify five major risk factors related to <BR/>employee behaviors and preparation practices in retail and food service establishments <BR/>as contributing to foodborne illness: <BR/>o Improper holding temperatures, <BR/>o Inadequate cooking, such as undercooking raw shell eggs, <BR/>o Contaminated equipment, <BR/>o Food from unsafe sources, and <BR/>o Poor personal hygiene <BR/>The Food Code addresses controls for risk factors and further establishes 5 key public health interventions to protect consumer health. Specifically, these interventions are: <BR/>demonstration of knowledge, employee health controls, controlling hands as a vehicle of contamination, time, and temperature parameters for controlling pathogens, and the consumer advisory. The first two interventions are found in Chapter 2 and the last three in Chapter 3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers.<BR/>The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled.<BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADLs to include feeding assistance and impaired vison. <BR/>Record Review of the shower log, in the 300-domain area, for Resident #1 revealed the last time Resident #1 took a shower was 12/26/2023. There were no other shower entries for Resident #1 from 12-27-2023 through 1-20-2024. <BR/>In an interview with Resident #1, on 1/20/2024, at 1:12 PM, revealed that Resident #1 had not had a shower in 3 weeks. Resident #1 stated she wanted to take a shower at least once a week. <BR/>Record review of Resident #5's Face Sheet dated 1-20-2024, showed an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had a primary diagnosis of pneumonia unspecified organism, chronic atrial fibrillation unspecified (the heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles)), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and reduced mobility. <BR/>Record Review of the facility's ADL Dependent Resident Report dated 1-20-2024, indicated Resident #5 was an ADL Dependent Resident of the facility and needs assistance bathing. <BR/>In an interview with Resident #5, on 1/20/2024, at 4:10 PM, it was conveyed that Resident #5 needed ADL assistance as she loses her balance. Resident #5 revealed she had not been bathed as often as she wanted to. Resident #5 wanted to get showered at least twice a week. Resident #5 stated that she had gone over a week without getting a bed-bath. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that the showers in the 300-domain hall, has not had hot water. Resident #2 conveyed that she has not had a shower in 3 weeks and there has not been hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of ADL assistance. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis (a condition in which too much acid accumulates in the body). <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was expressed that the Resident's bathroom had not had hot water for weeks and Resident #7 had not had a shower for over a week or two. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>Record review of the shower log for Resident #7 disclosed that Resident #7 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 had a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8's room had not had hot water for over a week and Resident #8 had not had a shower in a week or two. Resident #8 would like to get a shower every couple of days.<BR/>Record review of the shower log for Resident #8 disclosed that Resident #8 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 had a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism (a disorder of the central nervous system that affects movement), often including tremors., unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room had not had hot water for over a week and Resident #9 had not had a shower in over a week. Resident #9 stated that he would like to have a shower every other day and he did not want to take a cold shower. <BR/>Record Review of the shower log for Resident #9 indicated Resident #9 refused a shower on 1-18-2024. There were no other shower logs for Resident #9 for the year of 2024. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was disclosed that his expectation was that residents were offered showers in other units, even if their unit, does not currently have hot water. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was revealed that her expectation was that a staff members would take a resident to another unit to get a shower, if the resident's unit does not have hot water. The DON stated that staff, in the 300 unit, where the hot water was temporarily out, have been instructed to take residents, who want a shower, to another unit. The DON stated that it was her expectation that staff did not offer a cold shower to a resident if there is a shortage of hot water. <BR/>Record Review of the facility's undated Bath, Tub/Shower Policy stated .The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of five residents reviewed for discharge. The facility failed on 8/21/2025 to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs in that Resident #1 did not go to the Resident Representative's (RP) home, Resident #1 was taken to another family members residence because Resident #1 RP couldn't care for her due to work schedule and on or about 25 or 26 August 2025 Resident #1's RP obtained an order of protective custody for Resident #1 and Resident #1 was arrested and taken to a psychiatric hospital.This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met.This failure resulted in an Immediate Jeopardy situation on 9/16/2025. While the IJ was removed on 9/18/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to staff needing more time to monitor the effectiveness for the plan of removal for inappropriate discharge. Findings included:Record review of Resident #1's Discharge summary, dated [DATE], revealed a [AGE] year-old female originally admitted on [DATE], re-admitted on [DATE], and discharged on 08/21/2025. Resident #1 had diagnoses which included: Cellulitis of left lower limb (bacterial infection of the skin and underlying tissues), acute respiratory failure with hypercapnia (inability of the lungs to effectively remove carbon dioxide), morbid (severe) obesity with alveolar hypoventilation (breathing disorder), diabetes mellitus (high blood sugar) without complications, unsteadiness on feet, lack oof coordination, generalized anxiety disorder (mental health conditions), dementia in other diseases classified elsewhere (a type of dementia that occurs as a secondary symptoms of another underlying medical condition), severe with mood disturbance, pain unspecified, reduced mobility, difficulty in walking, deficiency of other vitamins, unspecified intellectual disabilities, schizoaffective disorder (mental condition that combines symptoms of schizophrenia and a mood disorder), bipolar (manic depression), fluid overload, unspecified pyuria (high levels of white blood cells in urine), lymphedema (swelling in the body), iron deficiency anemia, pulmonary hypertension (blood pressure in the arteries of the lungs is abnormally high), acute on chronic diastolic (congestive) heart failure, acute embolism and thrombosis of deep veins of unspecified lower extremity (blood clot in the deep veins of the lower leg), acute embolism and thrombosis of superficial veins of left upper extremity (new blood clot forming in a superficial vein in the left arm, or shoulder, which may involve a clot traveling through the bloodstream), muscle weakness, need for assistance with personal care, cognitive communication deficit person's ability to communicate effectively due to underlying impairments), acute cystitis without hematuria (inflammation of the bladder (cystitis) that does not involve blood in the urine (hematuria). The reason for the discharge reflected an incident with another resident causing bodily harm. The discharge effective date was 8/21/2025. Brief history for Resident #1 reflected an increase in unsafe behaviors towards residents. The course of treatment for Resident #1 reflected interventions of increased activities and time in a calming environment. The condition Resident #1 discharged reflected was good. Rehabilitative Potential for Resident #1 reflected fair. The follow-up and discharge medications (instructions to resident) revealed the following medications were sent home for Resident #1: Depakote ER Oral Tablet, Seroquel Calcium Carbonate Tablet Chewable 500 MG, Maalox Regular Strength Suspension Potassium Chloride ER Lasix Oral Tablet 20 MG, Multivitamin-Minerals Oral Tablet, Tylenol Extra Strength Oral Tablet 500 MG, Vitamin B12, Ergocalciferol Capsule 50000 UNIT, Zoloft Oral Tablet, Anoro Ellipta Inhalation Aerosol Powder Breath Eucerin, External Lotion Metformin Gentamicin Sulfate External Ointment 0.1 % Albuterol Sulfate HFA Inhalation Aerosol Solution. Resident #1 was discharged home with no home health. The list of reconciled medications sent with the representative reflected yes. How was the list of reconciled medication sent reflected verbal. Digitally signed by the physician. Record review of Resident #1's quarterly MDS assessment, dated 06/04/2025, revealed Resident #1 did not perform an interview for mental status due to the resident rarely/never understood. Resident #1's behavior revealed no exhibited physical behavioral symptoms directed toward others, no exhibited verbal behavioral symptoms director toward others and no exhibited other behavioral symptoms directed toward others. Record review of Resident #1's Care Plan, dated 02/21/2025, revealed Resident #1 would remain in the facility for long term as she required 24-hour licensed nursing care. Resident #1 required anti-psychotic and anticonvulsant medications for diagnoses of schizophrenia, psychosis, and bipolar disorder could show aggressive behavior during periods of frustration or agitation. Record review of Resident #1's referral from the hospital to Five Points at Highlands, dated 7/28/2023, revealed Resident #1's RP stated she could not care for Resident #1 any longer, and would need somewhere long-term, possibly with a secured unit to prevent Resident #1 from trying to leave. Record review of the NP progress note, dated 08/21/2025, revealed when the NP arrived on the secured unit and there were two officers conversing with the ADON and SW. Resident #1 was in the dining room with the sitter. Police informed staff that they cannot arrest Resident #1 due to her mental capacity, nor could they detain her with OPC because she was in a facility where she could receive medical care. Resident #1's RP was informed that Resident #1 was a danger to others and was receiving immediate discharge notice. The SW explained to Resident #1's RP that she could take Resident #1 to psych hospital, but the officers could not take her. The NP stated Resident #1's RP wanted police to take Resident #1 because she could not force Resident #1 to do anything. The NP encouraged her to call family members to assist her, Resident #1 had an immediate family member, but RP told NP that he will make things worse. Record review of the SW progress note, dated 8/22/2025, revealed the SW notified of the altercation between Resident #1 and another resident. SW contacted Resident #1's RP to notify her of the altercation and the order for immediate discharge. Resident #1's RP came to the facility to pick up Resident #1 and take her home with medication, a rollator, instructions, and community referrals for medical PCP and discharge from the facility. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of request and/or referral for psych observation for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP declined alternate placement for Resident #1. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation that Resident #1's RP received the facility Ombudsman's contact information to assist discharge to the community. Record review of Resident #1's electronic health records from 8/21/2025 to 8/28/2025 revealed no documentation of verbal or written notice of intent to leave the facility. In a confidential staff interview on an undisclosed date, it was revealed that Resident #1's was not a safe discharge, and the RP could not properly care for Resident #1 because she had dementia, the resident was obese and had mood disorders and the RP was a small petite elderly woman who Resident #1 could potentially harm. During an interview on 8/28/2025 at 9:10 a.m., with the Administrator revealed there was an unwitnessed incident on the secured unit and when he and the SW notified Resident #1's RP to inform her they were going to send Resident #1 out to the hospital for behavior observation, the RP stated she would just pick Resident #1 up and take her home. The Administrator stated they conducted the discharge process for Resident #1 and the RP was provided with all Resident #1's medications, but her belongings were still in the facility due to the RP stating she could not fit them in the car. During an interview on 08/28/2025 at 09:39 a.m., with Resident #1's RP she revealed that she had received a phone call on 08/21/2025 from the facility SW who stated she had to pick up Resident #1 from the facility immediately because Resident #1 could no longer stay at the facility due to an unwitnessed incident that happened and she was being discharge immediately. The RP told the SW that she had nowhere to take Resident #1 and asked if she could get Resident #1 sent to another facility, because Resident #1 gave up her apartment when she admitted to the facility and would be homeless. She stated the SW insisted the RP pick up Resident #1. The RP stated when she arrived at the facility, they gave her some papers as she put Resident #1 in the car. The RP stated she would never have picked up Resident #1 voluntarily because the RP could not care for Resident #1 properly as Resident #1 required round-the-clock care and the RP stated she worked two part-time jobs. RP revealed Resident #1 never went to her home the RP took her to another family members home until she was able to obtain an order of protective custody and police arrested Resident #1 and took her to a psychiatric hospital. During an interview with the SW on 8/28/2025 at 12:45 p.m., the SW stated Resident #1 discharged on 8/21/2025. The SW stated she informed Resident #1's RP that she could refer Resident #1 to another facility, but Resident #1's RP declined and picked up Resident #1 and took Resident #1 home. The SW stated it was a safe discharge because she had attempted to offer to find placement for Resident #1, but it was declined verbally, and Resident #1 went home with a family member who was provided with referrals for community resources, a walker, and medications. In an interview on 8/28/2025 at 217 pm, with the Administrator revealed Resident #1's RP came and picked up Resident #1 that it was a safe discharge as the RP was responsible for making decisions for Resident #1 care. The Administrator stated if the RP could not take care of Resident #1 the RP would have elected someone who could. The Administrator stated that if the RP couldn't find Resident #1 placement at another facility, he would have to consult with his superiors on Resident #1's return to the facility as days had passed so Resident #1 would have to go through the referral process and start the admission process again. Record review of facility Discharge or Transfer policy dated 12/2017 revised 2/12/2025 under Resident Discharge to the Community states For resident who want to be discharged o the community, this nursing home must determine if appropriate and adequate supports are in place, including capacity and capability for the resident's caregivers home. Family members, significant others or the resident's representative should be involved in this determination, with the resident's permission, unless the resident is unable to participate in the discharge process. A referral to the Local Contact Agency may be appropriate for many individuals, who could be transitioned to a community setting of their choice. The nursing home staff is responsible for making referrals to the LCA, if appropriate, under the process that the State has established. Nursing home staff should also make the resident and if applicable, the resident representative, aware that the local ombudsman is available to provide information and assist with and traditions from the nursing home. For residents who have been in the facility for a longer time, it is still important to inquire, as needed, whether the resident would like to talk with LCA experts about returning to the community. If the resident is unable to communicate their preference or is unable to participate in discharge planning, the information should be obtained from the resident's representative. Discharge planning must include procedures for: -Documentation of referrals to local contact agencies, the local ombudsman, or other appropriate entities made for this purpose. -Documentation of the response to referrals; and -For residents for whom discharge to the community has been determined to not be feasible, the medical record must contain information about who made that decision and rational for that decision. Discharge planning must identify the discharge destination, and ensure it meets the resident's health and safety needs, as well as preferences. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility must treat this situation similarly to refusal of care, and must: -Discuss with the resident, (and/or his or her representative, if applicable) and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; -Document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; -Document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; -Determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at the time of discharge. An Immediate Jeopardy was identified on 9/16/25 and the Administrator was notified of the Immediate Jeopardy on 9/16/25 at 6:28 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The facility's POR for Immediate Jeopardy was accepted on 9/18/25 at 3:11 p.m. and reflected the following: . Interventions: 1. Resident #1 currently does not reside in the facility as of 8/21/25. The SW, and Administrator reached out to the RP of Resident #1 to discuss alternative placement due to increased behaviors. Resident #1's RP came to the facility to pick up the resident and take her home with medications, rollator, community resources for medical PCP. 2. All residents discharged in the past 30 days had their charts audited by the RCN, DON, and ADONs to ensure that all residents were discharged safely to their destination. 18 residents were discharged to the hospital. 3 residents discharged home. Initiated 9/16/25 and Completion Date 9/17/25. 3. The Administrator, DON, ADONs, and SWs were in-serviced 1:1 by ADO, RCN on 9/16/25 on the following topics. Initiated 9/16/25 and Completion Date 9/17/25. A. Discharge or Transfer to Another Facility Policy: New Process: Initiated 9/16/25 and Completion Date 9/17/25. In the future, if there is an emergency discharge scenario- all listed IDT members and PCP/MD will have a meeting to plan a safe discharge with all necessary community services. The charge nurses will report to DON and ADON if any part of the discharge process is overlooked or not completed. When a resident is discharged home, the following IDT members will perform the following: DON: Collaborate with IDT in the planning and ensure residents have all necessary post discharge providers in place for continuity of care. The DON's last day is 9/19/25. ADON A will be trained to follow the DON responsibilities on 9/17/25 and will resume the responsibilities for the discharge process on 9/19/25. ADONs: Family members will be educated on the care of the residents, including medications and psychology/psychiatry services to facilitate a safe discharge to a safe destination. The resident's attending physician and psych MD will be notified for the order and approval to discharge. ADONs A, B, and C are responsible for educating the PCP and psych services on upcoming discharges home as well as the community services for continuity of care. Social Workers: Ensure location and discharge address to Home Health Care if needed, order DME if needed. The SW will get in contact with resident and/or RP/family within 48 hours to ensure the resident is doing well and adjusting well in discharge location. The SW will document in Point Click Care ( PCC) in progress notes. The Administrator will check on all 48-hour discharge follow-ups during facility morning and end of day meetings on PCC. Administrator: Will ensure that every discharge has an IDT meeting completed and all providers for care are involved, and community resources are set up for discharge. The Administrator will ensure that all medications, DME and home health services are in place prior to discharge home. The SWs will document in PCC under progress notes the discharge location, post discharge services, home health services and caregiver support as needed. The Administrator is responsible for training the IDT on the discharge process and will check for every planned/unplanned discharge to ensure the process is followed for all discharges home by reviewing the documentation in PCC under progress notes and d/c summary. The Administrator will inquire about upcoming and unplanned discharges 5 days a week during morning facility and end-of-day meetings. The Administrator will report to the ADO weekly on the Operations Call for all home discharges. The ADO will audit all home discharges on PCC and verify with the facility IDT. Resident Rights Policy: All residents have the right to safely discharge with education provided for care, services, and medication. Behavioral Management Policy: Residents with behavioral or psychology diagnosis will have the appropriate care and services during admission and upon discharge. The SW will ensure that psychology services are in place when discharging a resident home. The MD was notified of the immediate jeopardy on 9/16/25 by the Administrator. An AD HOC (as needed) QAPI meeting was completed with interdisciplinary team which included the MD, Administrator, DON, Admissions, and BOM to discuss the citations and plan of removal. Initiated 9/16/25 and Completion Date 9/17/25. The Administrator/designee will test the IDT and charge nurses on the discharge process. Return demonstration via testing will need to be 100% prior to their shift. If 100% is not achieved- re-education will be provided until 100% compliance is achieved. Initiated 9/16/25 and Completion Date 9/17/25. Residents who have increased behaviors will be monitored every shift for safety by the nurse charge and will report daily to the DON and ADONs and notify the MD. There are 3 residents that are currently be monitored for behaviors (see attached). Training: ADON A will be responsible for educating and testing PRN and staff that are on vacation during this time period. ADON A will update the Administrator on the progress with education and testing 5 days a week until completed. Initiated 9/16/25 and Completion Date 9/17/25. For all immediate discharges: the Administrator will notify the Area Director of Operations prior to discharge. The ADO will verify the discharge process was followed correctly for a safe discharge. Initiated 9/18/25 and Completion Date 9/18/25. In-services: All charge nurses were in-serviced on the following topics by the Administrator, DON, ADONs. All nurses not present and PRN staff will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. Initiated 9/16/25 and Completion Date 9/17/25. Discharge or Transfer to Another Facility Policy: New Process: The charge nurse will educate the resident RP/family on medication review, count narcotics if any, and complete the DC summary in PCC at the time of discharge. The Charge Nurses will report to the DON and ADONs if any part of the discharge process is overlooked or not completed. Monitoring of the plan of removal included:Record review of facility in-services titled Behavior Management and documentation, Discharge Planning Process and Documentation, Discharge Planning Process policy, and Resident Rights, dated 9/16/25 though 9/18/25, reflected staff were educated by the Administrator, DON, and ADONs.Record review of a one-on-one in-service titled Resident Rights, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Discharge Plannings Process and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of a one-on-one in-service titled Behavior Management and Documentation, dated 9/16/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO. Record review of a one-on-one in-service titled Notify ADO of any Immediate Discharge, dated 9/18/25, reflected 4 (Administrator, DON, and two Social Workers) staff were educated by the ADO.Record review of 30-Day Discharges identified two additional residents had discharged from the facility Resident, Resident #2 left against medical advice and resident #3 discharged back home after five days of respite care. Record review of the Administrator, DON, ADONs, SWs and Charge Nurses test on discharge process reflected they had 100% accuracy. Record review of the AD HOC QA meeting held on 9/16/25 reflected the meeting consisted of Administrator, DON, MDS, Medical Director, and Business Office Manager.Record review of ,residents identified for monitoring for behaviors, Resident #4, Resident #5 and Resident #6's electronic health records from 9/18/25 to 9/19/25 reflected they were monitored for behaviors. Interview with the ADO on 9/18/23 at 3:15 p.m. He stated he trained the Administrator and DON on the notification to ADO of any immediate discharge. Additionally, re-trained the Administrator, DON, and SWs on the discharge planning process and documentation, resident rights, Behavior management and documentation. Verified via record review signed by the Administrator, DON and both social workers. Interview with Administrator on 9/18/25 at 3:30 p.m., the Administrator stated the ADO re-educated him on the discharge planning process and documentation, resident rights, behavior management and documentation and the ADO trained him on the notification to ADO of any immediate discharge Interview with the DON, on 9/18/25 at 3:45 p.m., the Administrator was asked, what was the facility's monitoring or oversight process for ensuring residents were discharged safely. He responded his plan was for this to be a continuous quality measure; that started with the IDT team which consist of the resident and/or their resident representative, medical director, social worker, nursing, therapy, DON and Administrator which will ensure the resident is prepared, educated and discharged safely. The medical director approved the discharge, the social worker ensured medical equipment was ordered, referrals were placed and community services were set up and documented in PCC, the follow up 48 hours post discharge to make sure discharge was smooth and document response in PCC. The ADONs and/or charge nurse would review and educate resident and/or resident representative on medication and document in PCC. The Administrator would ensure all discharge process were followed. To ensure each steps where completed the Administrator would review the documentation was completed in PCC. The Administrator stated that the steps were the same for an immediate discharge except he had to contact the ADO and inform him of the immediate discharged resident. During an interview on 9/18/25 at 5:00 pm with ADON A revealed that she had been trained by the DON on her duty to sit in fill in as interim DON in the IDT planning and ensure residents have all necessary post discharge providers in place for continuity of care. Verified via record review of Resident #5 who resided on the secured unit showed increased behaviors and charge nurses documented Resident #5 increased behaviors in PCC. Charge nurse contacted ADON A, ADON A contacted the MD, the MD put in a psych evaluation order, Resident #5 RP contacted and Resident #5 discharged to the hospital. Interviews held on 9/18/25 from 3:15 p.m., to 6:00 p.m., and 09/19/25 from 6:00 a.m., to 5:40p.m., which covered staff who work morning, day, night shifts, PRN staff and double weekend staff conducted with the Administrator, DON, ADON A (1st shift/weekdays), ADON B(1st shift/weekdays), ADON C (1st shift/weekdays), RN D (weekdays), RN E (PRN), RN F (overnight/morning), RN G (overnight/morning), RN H (double weekends), LVN I (Overnight), LVN J (morning), LVN K (overnight), LVN L (second shift), LVN M (double weekends) and SW N, SW O indicated they all participated in in-services on resident rights, discharge process and documentation and proficiency test prior to starting their shifts. All staff knew their responsibilities. All staff were knowledgeable, who were a part of the IDT. All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understand that the Administrator would oversee the entire process to make sure it was complete, and he would report any immediate discharges to the ADO. The Administrator was informed that the Immediate Jeopardy was removed on 9/18/2025 at 3:11 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of isolated, due to staff needing more time to monitor the effectiveness of the plan of removal for inappropriate discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers.<BR/>The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled.<BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADLs to include feeding assistance and impaired vison. <BR/>Record Review of the shower log, in the 300-domain area, for Resident #1 revealed the last time Resident #1 took a shower was 12/26/2023. There were no other shower entries for Resident #1 from 12-27-2023 through 1-20-2024. <BR/>In an interview with Resident #1, on 1/20/2024, at 1:12 PM, revealed that Resident #1 had not had a shower in 3 weeks. Resident #1 stated she wanted to take a shower at least once a week. <BR/>Record review of Resident #5's Face Sheet dated 1-20-2024, showed an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had a primary diagnosis of pneumonia unspecified organism, chronic atrial fibrillation unspecified (the heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles)), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and reduced mobility. <BR/>Record Review of the facility's ADL Dependent Resident Report dated 1-20-2024, indicated Resident #5 was an ADL Dependent Resident of the facility and needs assistance bathing. <BR/>In an interview with Resident #5, on 1/20/2024, at 4:10 PM, it was conveyed that Resident #5 needed ADL assistance as she loses her balance. Resident #5 revealed she had not been bathed as often as she wanted to. Resident #5 wanted to get showered at least twice a week. Resident #5 stated that she had gone over a week without getting a bed-bath. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that the showers in the 300-domain hall, has not had hot water. Resident #2 conveyed that she has not had a shower in 3 weeks and there has not been hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of ADL assistance. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis (a condition in which too much acid accumulates in the body). <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was expressed that the Resident's bathroom had not had hot water for weeks and Resident #7 had not had a shower for over a week or two. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>Record review of the shower log for Resident #7 disclosed that Resident #7 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 had a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8's room had not had hot water for over a week and Resident #8 had not had a shower in a week or two. Resident #8 would like to get a shower every couple of days.<BR/>Record review of the shower log for Resident #8 disclosed that Resident #8 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 had a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism (a disorder of the central nervous system that affects movement), often including tremors., unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room had not had hot water for over a week and Resident #9 had not had a shower in over a week. Resident #9 stated that he would like to have a shower every other day and he did not want to take a cold shower. <BR/>Record Review of the shower log for Resident #9 indicated Resident #9 refused a shower on 1-18-2024. There were no other shower logs for Resident #9 for the year of 2024. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was disclosed that his expectation was that residents were offered showers in other units, even if their unit, does not currently have hot water. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was revealed that her expectation was that a staff members would take a resident to another unit to get a shower, if the resident's unit does not have hot water. The DON stated that staff, in the 300 unit, where the hot water was temporarily out, have been instructed to take residents, who want a shower, to another unit. The DON stated that it was her expectation that staff did not offer a cold shower to a resident if there is a shortage of hot water. <BR/>Record Review of the facility's undated Bath, Tub/Shower Policy stated .The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that the<BR/>Resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. <BR/>The facility failed to ensure Resident #1 had an environment free of accident hazards by not keeping her bed at a safe angle while being fed thereby preventing a choking hazard. <BR/>This failure affected residents by placing them at risk for choking and aspiration. <BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADL to include feeding assistance and impaired vison. <BR/>Review of Resident #1's Care Plan, dated 8/28/2023, disclosed Resident #1 was ADL Performance Deficient requiring total assistance to eat, bath, and reposition in bed. <BR/>In an observation on 1/20/2024, at 1:15 PM, Resident #1 was observed being fed by CNA-A while Resident #1's bed angle was significantly below a 45-degree angle. Resident #1's neck was observed turned to her left side, at a low angle, while CNA-A was feeding her meatballs and spaghetti. Resident #1's bed angle was observed to never change the entire time Resident #1 was being fed. <BR/>In an interview with the Administrator on 1-20-2024, at 7:00 PM, it was disclosed that his expectation of the angle a resident should be fed at, while lying in bed, depends on the diagnosis, catering to the resident's preferences, and safety. The Administrator's expectation was the feeder should try to prevent aspiration and pain. <BR/>In an interview with the DON on 1-20-2024, at 7:38 PM, it was disclosed that her expectation for the angle of a bed to be at, when a resident was being fed by staff, was for the bed to be between 30-45-degree angle. The DON stated that some family members have requested a resident's bed to be at a 60-degree angle while being fed. The DON stated that it was the responsibility of the nursing staff to make sure a resident's bed was at a safe angle for feeding. The DON stated it was also the responsibility of the CNA's, doing the feeding, to ensure the resident's bed was at a safe angle for feeding but mostly the responsibility falls on the nurses.<BR/>Record review of the facility's policy on Feeding, Assistive/Complete, that is non-dated, stated . It is important to allow and encourage as must independence in self-feeding as possible to enhance self-worth and provide optimal control of daily living activities. The goal is for <BR/>1. The resident will achieve maximal participation in daily self-feeding .The Procedures are <BR/>3. Explain the procedure and expected results to the resident .<BR/>5. Position the resident for comfort. Use high [NAME]=s while sitting in bed (High [NAME] was a supine position in which an individual lies on their back on a bed, with the head of the bed elevated between 60-90 degrees, and the legs of the patient can be either straight or bent at the knees).<BR/>6. Provide a pleasant environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. <BR/>The facility did not put a floor mat for Resident #1 as indicated in his care plan as an intervention in the resident's care plan who was a high fall risk while he was in his bed on 05/14/25. <BR/>This failure can put residents at risk for falls to sustain injuries due to not following interventions for fall precautions in place.<BR/>The findings included:<BR/>Record review of Resident #1 admission record dated, 05/14/25, revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included Unspecified Parkinsonism (a progressive nervous system disorder, which affects the ability to move muscles and muscle spasms or jerks), involuntary abnormal movements, cognitive communication problem, need for assistance with personal care, and prostate cancer.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/08/25 revealed, Resident #1 rarely made himself understood, but he sometimes understood others. Resident #1 was dependent on staff for ADLs. Further the MDS revealed Resident #1 had a fall since admission and or reentry to the facility. MDS did not reflect BIMS.<BR/>Record review of Resident #1's care plan revised on 04/13/24 revealed Resident #1 had a high fall risk related to unsteady gait and lack of awareness. The goal was for Resident #1 to be free from minor injuries until the next review date. The interventions included fall mat at bedside. <BR/>Observation and interview with Resident #1 on 05/14/25 at 10:20 AM, revealed Resident #1 was in bed lying on his back, awake and attempting to climb out of bed. He had the call light within reach, his bed was in lowest position, and he was on a pressure relieving mattress with a pillow under both his knees. Resident #1 stated he was doing well. He said that he knew how to use the call light if he needed anything. Resident #1 did not have a floor mat next to his bed.<BR/>Observation and interview on 05/14/25 at 10:34 AM , revealed ADON went to storage room and took a floor mat and took it to Resident #1's room and placed it on the floor next to Resident #1's bed. The ADON said the CNA may have removed Resident #1's floor mat to get cleaned because it was dirty with food. He said the overnight shift will usually remove the mats in the morning to avoid them being a tripping hazard for the residents. The ADON said the expectation was that when the resident was in bed and he was a fall risk, the interventions for fall, needed to be flowed. He said he was going to do an in-service making sure that fall precautions are in place.<BR/>In an interview with CNA E on 05/14/25 at 10: 48AM, revealed she had put Resident #1 in bed when she noticed him falling asleep in the TV room. She said that she made sure that he had his call light, and his bed was in the lowest position. She said she did not see a floor mat in Resident #1's room this morning when she got Resident #1 up and when she put him in bed after breakfast. She said she was not aware that he required a floor mat because she hardly worked with Resident #1. She said the CNA that was familiar and usually worked with him had called in today. She said she should have asked his nurse if he required a floor mat. She said she checked on residents that are known to be fall risks frequently and kept their doors open so that any staff passing by can see them if they are trying to get out of bed without calling and assisting them . She said the floor mat as a fall intervention, would help to cushion Resident #1 if he fell out of bed. She said the risk to the resident was if he fell, he would hit the floor and hurt himself.<BR/>In an interview with LVN F on 05/14/25 at 10:37 AM, she said she was Resident #1's nurse and CNA E was assigned to him today. She said she did not work on Monday; therefore, she does not know what happened to Resident #1's floor mat. <BR/>She said the floor mat was a fall intervention required for Resident #1 and should be in place. She said floor mats can be a tripping hazard so the CNAs usually will remove them when helping the residents out of bed or when caring for them in bed.<BR/>In an interview with DON on 05/14/25 at 2:09 PM, it was revealed Resident #1 had a lot of interventions for fall in place including being moved from the secure unit so that he could be closer to the nursing station for quick response and availability to staff. She said the floor mat was part of his fall precaution and the expectation was that when Resident was in bed, it should be on the floor next to his bed. She said it was possible someone moved it out of the way while providing care. <BR/>In an interview with the ADM on 05/14/25 at 4:40 PM, she expected staff to provide interventions as needed, as scheduled, or as requested and to document what was provided. <BR/>Record review of facility policy titled Preventive Strategies to Reduce Fall Risk revision date 10/05/16 reflected:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by<BR/>eliminating or managing contributing factors while maintaining or improving the resident's mobility.<BR/>8. Education: . Do not assume that individuals can figure out these things by themselves . Educate family members about safety measures and fall prevention. Provide instruction on how to identify risk and environmental hazards. Document education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers.<BR/>The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled.<BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADLs to include feeding assistance and impaired vison. <BR/>Record Review of the shower log, in the 300-domain area, for Resident #1 revealed the last time Resident #1 took a shower was 12/26/2023. There were no other shower entries for Resident #1 from 12-27-2023 through 1-20-2024. <BR/>In an interview with Resident #1, on 1/20/2024, at 1:12 PM, revealed that Resident #1 had not had a shower in 3 weeks. Resident #1 stated she wanted to take a shower at least once a week. <BR/>Record review of Resident #5's Face Sheet dated 1-20-2024, showed an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had a primary diagnosis of pneumonia unspecified organism, chronic atrial fibrillation unspecified (the heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles)), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and reduced mobility. <BR/>Record Review of the facility's ADL Dependent Resident Report dated 1-20-2024, indicated Resident #5 was an ADL Dependent Resident of the facility and needs assistance bathing. <BR/>In an interview with Resident #5, on 1/20/2024, at 4:10 PM, it was conveyed that Resident #5 needed ADL assistance as she loses her balance. Resident #5 revealed she had not been bathed as often as she wanted to. Resident #5 wanted to get showered at least twice a week. Resident #5 stated that she had gone over a week without getting a bed-bath. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that the showers in the 300-domain hall, has not had hot water. Resident #2 conveyed that she has not had a shower in 3 weeks and there has not been hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of ADL assistance. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis (a condition in which too much acid accumulates in the body). <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was expressed that the Resident's bathroom had not had hot water for weeks and Resident #7 had not had a shower for over a week or two. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>Record review of the shower log for Resident #7 disclosed that Resident #7 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 had a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8's room had not had hot water for over a week and Resident #8 had not had a shower in a week or two. Resident #8 would like to get a shower every couple of days.<BR/>Record review of the shower log for Resident #8 disclosed that Resident #8 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 had a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism (a disorder of the central nervous system that affects movement), often including tremors., unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room had not had hot water for over a week and Resident #9 had not had a shower in over a week. Resident #9 stated that he would like to have a shower every other day and he did not want to take a cold shower. <BR/>Record Review of the shower log for Resident #9 indicated Resident #9 refused a shower on 1-18-2024. There were no other shower logs for Resident #9 for the year of 2024. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was disclosed that his expectation was that residents were offered showers in other units, even if their unit, does not currently have hot water. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was revealed that her expectation was that a staff members would take a resident to another unit to get a shower, if the resident's unit does not have hot water. The DON stated that staff, in the 300 unit, where the hot water was temporarily out, have been instructed to take residents, who want a shower, to another unit. The DON stated that it was her expectation that staff did not offer a cold shower to a resident if there is a shortage of hot water. <BR/>Record Review of the facility's undated Bath, Tub/Shower Policy stated .The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (Emergency Response Cart 1) emergency crush carts reviewed for emergency preparedness.<BR/>Facility failed to check inventory daily on an Emergency Response Cart 1 on C hallway from [DATE] to [DATE].<BR/>These failures could place residents at risk for delayed emergency response care.<BR/>The findings included: <BR/>Review of Emergency Response Cart 1's daily log inventory check off on [DATE] at 09:46 AM, revealed no check off was completed from [DATE] to [DATE] on Emergency Response Cart 1. Further review of the daily Emergency Response Cart 1 inventory log revealed it was also incomplete for [DATE] with the following items not checked off; Kling (a type of gauze bandage), blood pressure cuff, stethoscope, K-Y- jelly, and Backboard (this is a board required when doing CPR). <BR/>In an interview with RN A on [DATE] at 09:50 AM, he was the charge nurse of the C hallway. He revealed the night 10 PM-6 AM shift were responsible for making sure that the emergency response carts were checked off nightly. He said each hallway had its own emergency response cart. RN A was observed investigating the emergency response cart and he stated all items were available on Emergency Response Cart 1. He said he did not know why Emergency Response cart 1 was not checked off nightly. He said that it was important to make sure that the inventory log had been signed and each item checked off to make sure emergency response items were on the cart. He said the risk of not checking the emergency response cart was they would not know if items needed for an emergency were missing.<BR/>In an interview with LVN B on [DATE] at 4:09 PM, she said she usually checked off the emergency response carts whenever she worked the night shift 10PM-6AM. She said each hallway had its own emergency response cart and the nurses on that hallway were responsible to checking off their emergency response carts. LVN B said she made sure that the emergency response carts in her hallway [B hallway] were always checked off nightly and she expected the other nurses on the other hallways to do so. She said the risk of not checking the emergency response carts were items required to respond in an emergency would be missing.<BR/>In an interview with ADON on [DATE] at 10:37AM, he said the night shift nurses were responsible for emergency response carts checking off crash carts nightly. He said the charge nurses were supposed to monitor that it was done. He said the expectation was that all emergency response carts were working and accounted for to make sure all items were on the emergency response cart in case of an emergency. ADON said all nurses were responsible for making sure that the emergency response carts had all items needed. He said it was important to check the emergency response cart daily so that you it would not place a resident at risk in case of an emergency in the facility by delaying care. <BR/>In an interview with DON on [DATE] at 2:09 PM, she stated the expectations were the nurses maintained the emergency response cart and it would be ready when they have a code and that the carts were being monitored by the charge nurses. She stated she would in-service and make sure the emergency response carts inventory logs were checked off and up to date and ready in case of a code blue episode so that there was no delayed care for a risk during a code.<BR/>In an interview with ADM on [DATE] at 4:40 PM, she said the expectation for staff were to complete checks of emergency response carts and document that it was being done. She said it was important to be checked daily because at any moment the emergency response carts could be needed when responding to a code blue, therefore, making sure everything was on the emergency response carts was important. <BR/>Record review of facility Central Supply Reference Guide dated 10/1023 reflected ALL Closets, all shelves, all bins, as well as the crash cart will be checked for expired items.<BR/>The facility did not have a policy for Cardiopulmonary Resuscitation.<BR/>

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 1 of 5 rooms observed.<BR/>The metal vent cover was missing from the air conditioning opening in the ceiling.<BR/>The built-in dresser was missing 4 dresser drawers and 2 dresser doors. <BR/>This facility failure could place Residents at risk for an unsafe environment. <BR/>Findings include: <BR/>Record review of Resident #2's face sheet dated 05/14/2025 revealed a [AGE] year-old admitted [DATE] with a readmission on [DATE]. Admitting diagnosis of Acute and Chronic Respiratory Failure with Hypercapnia (the inability to adequately remove carbon dioxide from the blood, leading to elevating levels of CO2 in the blood (hypercapnia) ; Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation (sudden worsening in airway function and respiratory symptoms in patients with COPD (a group of lung diseases that block airflow and make it difficult to breathe) ; Essential (Primary) Hypertension (high blood pressure where the underlying cause is unknown).<BR/>Record review of Resident #2's discharge assessment - return anticipated MDS dated [DATE] reveals BIMS score noted to be 15/15 with memory intact. Resident #2 needs partial to substantial/max assistance with ADL care. Resident #2 has shortness of breath or trouble breathing with exertion, sitting at rest, and when lying flat. <BR/>Record review of Resident #2 physician orders reveals continuous oxygen 2-4 lpm via nasal cannula or cylinder to keep O2 levels at or great that 93% every shift r/t Acute and Chronic Respiratory Failure with Hypercapnia (the inability to adequately remove carbon dioxide from the blood, leading to elevating levels of CO2 in the blood (hypercapnia).<BR/>Record review of Resident #2's care plan revealed resident will have no s/sx of poor oxygen absorption through the target date. (06/23/2025) Interventions are to give medications, monitor side-effects and effectiveness, deliver oxygen through<BR/>nasal cannula during meals, monitor s/sx of respiratory distress and report to MD PRN.<BR/>In an interview on 05/14/2025 at 11:55 am with Resident #2's revealed that her room is too hot. Resident #2 revealed that she has a hard time sleeping and breathing at night. Observed resident was using oxygen while up in her wheelchair. Resident states she must use her oxygen 24 hours a day.<BR/>Observation on 05/14/2025 at 12:10 pm in room [ROOM NUMBER] revealed the metal vent cover was missing from the air conditioning opening in the ceiling. Observed a large amount of black substance up in the ceiling area of the opening attached to the metal tubing. Warm air was blowing out of the opening. The room was warm with no air circulating. <BR/>Observed the built-in dresser with 4 missing dresser drawers and 2 dresser doors. Resident #2's personal clothes were thrown in the dresser at the bottom. The metal brackets were exposed that could be hazardous to Resident #2 and causing injury.<BR/>In an interview on 05/14/2025 at 3:06 pm with maintenance assistant revealed he has been at the facility just over a month. He hasn't worked in long term care before. What about the thermometer he was holding and what he was doing? <BR/>Maintenance assistant revealed he was checking room temperatures. He started checking at 12:45 pm. Why was he checking the temperatures. He revealed it because it was the hottest day of the year so far. Have any residents complained of being too hot? Has resident in room [ROOM NUMBER] complained of being too hot? After checking room [ROOM NUMBER], the maintenance assistant revealed her room temp is 74. He is checking temps every 30 minutes. Maintenance assisted stated the maintenance director was on vacation. Proceeded to Hall 3 of the building with maintenance assistant. At 3:13 pm in room [ROOM NUMBER], the maintenance assistant said the average was 73.8. He proceeded to point the thermometer at all walls in the room. Why was the ceiling tile and metal vent cover removed? Said it just fell off. Temped the vent by window, read 67. Vent with ceiling cover removed was 74.7. Stated assumed it was the return air vent. Does it feel warm here? The maintenance assistant stated that he sweats a lot, not like a normal person. Today at 2:15 pm it was fine. Shown picture with ceiling piece missing. Said he wasn't looking, I didn't notice. Just more focused on taking the temps. Do you know why it's off? He revealed, no idea. Does it affect the air? It should, because the warm air is coming down, having it uncovered makes it a little warmer, it's allowing the warm air to come through.<BR/>Went to the following rooms with temps:<BR/>334 - 72 average. <BR/>330 - 74 average. <BR/>Is this the average temp in the room? Yes. <BR/>Who is responsible for responding to complaints of hot or cold room temps? Normally ask the Maintenance Director. <BR/>What is the risk? I'm assuming there is always a risk, sweating, passing out. Overheated? Yes. <BR/>On days like today, why is it important to make sure AC working? Make sure the residents are comfortable, not too hot, so they won't pass out, sweat excessively and be comfortable. <BR/>Do you know what the temp is supposed to be? 74-78 is supposed to be okay.<BR/>This section (300 hall)? It's a different unit, it was built in phases. Way back then they used a different system, so not 100% sure what exactly sure what system controls what. <BR/>In an interview on 05/14/2025 at 5:30 pm the ADM revealed that she was not aware of the vent cover missing in room [ROOM NUMBER]. Revealed the black substance observed up inside the vent. Revealed to ADM that Resident #2 complained of her <BR/>room being too hot causing problems with sleeping and difficulty breathing. Do you know there are 4 drawers and 2 doors missing from the built-in dresser? The ADM revealed that she was aware of this, and the dresser is old and was not able to be repaired before Resident #2 moved into that room from another room. Maintenance will work on these repairs.<BR/>Record review of facility's policy on Self-Reporting Protocols - Air Conditioning<BR/>Failures if Outdoor Temperature is or will be 90 Degrees or Above revealed in<BR/>part, Do the following: Identify the source of the issue (air handler, electricity, fire system relays, etc); Utilize the Extreme Heat Procedure from the Emergency Prepares Binder .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident's property for one (Resident #1) of five residents reviewed for injuries of unknown origin.<BR/>The facility staff failed to report an injury of unknown origin to the abuse and neglect coordinator when Resident #1 sustained a large bruise to her right and left eyes and laceration to her right eyebrow. <BR/>This failure could place the residents at risk for further potential abuse due to unreported and uninvestigated allegations of abuse, neglect, and injuries of unknown origin.<BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/25 reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions), dementia with mood disturbance (a decline in cognitive function with behavioral disturbances due to the progressive deterioration of brain cells), muscle weakness, dysphagia (difficulty in swallowing food or liquid), lack of coordination, type 1 diabetes (a chronic disease that occurs when the body's immune system destroys the insulin-producing cells in the pancreas), malnutrition, schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors), and repeated falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed her BIMS score was 05, which indicated severe cognitive impairment. She had unclear speech and sometimes understood others. Resident #1 had no signs or symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no verbal or physically aggressive behaviors, and no rejection of care. Resident #1's assessment reflected she wandered daily. Resident #1 had no range of motion of issues and used a wheelchair for mobility and she required substantial/maximum assistance for activities of daily living. Resident #1 weighed 91 pounds and was five foot three inches. <BR/>Record review of Resident #1's care plan dated 06/27/24 and last revised on 01/17/25 reflected she was at risk for falls due to her Huntington's diagnosis and had an unwitnessed fall on 01/13/25. She was also at risk for wandering and as an intervention, she was placed in the facility's secured unit. The care plan also reflected Resident #1 had a bruise on her left eye and cheek (updated on 12/18/24). Interventions included to identify potential causative factors and eliminate/resolve, when possible, monitor location/size of the bruise, and report any abnormalities to the MD. <BR/>Record review of Resident #1's nursing progress notes related to her injuries dated 01/13/25 revealed the resident had an injury of unknown origin with a hematoma to the back of her head and a bruise to the left eyebrow. The progress note further revealed at Resident #1 was unable to state what happened but the resident also said she fell. Resident #1 was sent to the ER and returned later that day with an order for a prophylaxis antibiotic for a hematoma to the back of her head. <BR/>Record review of the facility's incident reports to HHSC, related to Resident #1, revealed the ADM submitted a facility incident related to an injury of unknown origin for the injury to the back of Resident #1's head that was discovered on 01/03/25 and completed an investigation according to HHSC regulations.<BR/>Record review of a nursing progress notes five days later on 01/18/25, written by LVN A, reflected Resident #1 had a change in condition, stating in part, Writer observed resident being minimally responsive while lying in bed. VS 97/75/72 RR15 T97.6 O2 95 ra. RP notified of condition and stated that she was ok with res being admitted to hospital for further tx. PA notified and voiced understanding. DON notified as well. Res will be sent to [Hospital Name]. ER dept was called x2 and call was never picked up to give report.<BR/>Record review of Resident #1's most recent weekly skin assessment completed on 01/18/24 by LVN A, at her change of condition, reflected Resident #1 had bruising present on her face and eyes, as well as skin abrasions present on her bilateral knees, buttocks, hips, and right shoulder. A skin assessment completed prior to that on 01/13/24 by ADON B revealed Resident #1 had a bruise on her left eyebrow and a skin tear on her posterior head, an injury which had already been documented and investigated by the facility. <BR/>Record review of the facility incident reports from 01/13/25 through 01/22/24 reflected no incident report related to Resident #1's bruising and injuries documented in the skin assessment on 01/18/24. <BR/>An interview with LVN F on 01/22/25 at 12:10 PM revealed she was the morning charge nurse for Resident #1 during the weekdays. She last remembered seeing her the day before she was sent to the ER for a change of condition (01/17/24) and did not recall seeing any bruises on her face or body and no black eyes. She stated the bruise she did see on Resident #1 was a small one on her left temple. LVN F stated if she saw a change in a resident's skin, she would notify the ADM, the DON, the MD, the wound care nurse, the RP, and do an incident report so we are all on the same page. LVN F stated Resident #1 was not self-injurious but did walk with an unsteady gait and walked independently . <BR/>An interview with CNA G on 01/22/25 at 12:51 PM revealed she worked on the secured unit and although she was not Resident #1's assigned CNA for the past two weeks, she still saw her in the secured unit. She did not see any bruises or black eyes on her face or any injuries on her body. CNA G stated she had not seen Resident #1 fall and had not heard of any unwitnessed falls, but said the resident was very wobbly in her gait. <BR/>An interview with ADON B on 01/22/25 at 2:51 PM revealed potential indicators of physical abuse could be marks, any type of bruising, discoloration, scratches, and an injury of unknown origin. An injury of unknown origin was a bruise that if we see what didn't see what happened or cannot identify if blood work drawn, or even a fracture, if the resident fell of if it was pathological. ADON B stated a suspicious injury would be if she observed a bruise on the groin or buttock area and upper arm, or if the resident had bruises shaped like finger marks or bruises on the eye. If a resident had an injury of unknown origin, ADON B stated the facility would try to investigate what happened and would notify the administrator, the DON, the RP, But a lot of times you don't know because they bump into each other and things. ADON B stated when an injury of unknown origin was discovered, the charge nurse was supposed to be notified first, then that charge nurse would contact the administrator next since it was an injury of unknown origin and then notify the rest of the nursing management team. ADON B stated the potential harm of not investigating a resident with suspicious bruises or injuries was that one would not be able to tell if it was caused by another resident or staff member, And you are putting other residents at risk. ADON B stated she saw a photo on the DON's phone, that LVN A sent the DON over the weekend on 01/18/25, when Resident #1 was sent to the ER of her back abrasion injuries but did not see any photos of her face. ADON B stated Resident #1 was ambulatory and could move around on her own but had a recent change in her gait and was having more difficulty getting around and had more jerky movements. <BR/>An interview with the DON on 01/22/25 at 3:20 PM revealed that LVN A sent her a text on Saturday 01/18/25 stating he saw some marks on Resident #1 that looked like scratches and bruising on the boney parts of her body. LVN A wanted to know if the DON knew where those marks came from and that the resident was not acting like herself. LVN A told her that Resident #1 was not moving around much, just lying on the bed, not responsive to verbal stimuli but to painful stimuli, and inquired if the facility had gotten the approval to refer the resident to hospice. The DON stated she told LVN A to send Resident #1 to the ER since she was a full code. The DON stated Resident #1 fell quite often and she already had an area on the back of her head and left eyebrow from an unwitnessed fall a week prior which had been called into HHSC as a self-reported incident. The DON stated potential indicators of physical abuse could be bruising of unknown origin, skin tears of unknown origin, or a resident drawing back from people. The DON stated she did not observe any of those indicators with Resident #1. The DON stated an injury of unknown origin was one that could not be determined as to what happened and one could be investigated to see what happened but could never be definitive. The DON stated a suspicious injury was one that had a shape to it such as a finger, palm, or hand shaped bruise, a grabbing bruise, as well as multiple skin tears and bruising when the staff never see the resident bump into anything. If a resident had an injury of unknown origin or any bruises that could not be explained, the DON stated, The immediate thing is to make sure that person is safe, call me and then call [ADM] as the abuse/neglect coordinator in case we go into that (reporting to HHSC). We start the investigation and tell the nurse to do a head-to-toe assessment and to call the doctor depending on the injury. If the resident is sent out, the (charge) nurse needs to talk to me. If they hit their head, I want skull x-rays, hip x-rays, ankle x-rays and so forth since this is an older generation. The DON stated it was not up to anyone to determine if an injury or bruise was suspicious or not, it was to be reported to the nurse and then the nurse was to report it to the DON and the DON and ADM will look into it. The DON stated the potential harm of not investigating a resident with injuries of unknown origin including bruises were that the resident could potentially continue to be abused if that was occurring. The DON stated she felt when Resident #1 flails her hands, she could not control where her hands hit her body due to her diagnosis of Huntington's disease, so she did not know if that caused the current injuries on her face. She felt that Resident #1's injury to the back of the head came from an unwitnessed fall as well as a black eye the resident had in mid-December 2024 when she tore a frame picture off the wall in the secured unit and hit her eye with it. The DON stated when LVN A texted her, he did not mention the bruises on Resident #1's face. The DON stated she discovered that today (01/23/25) when she was reviewing Resident #1's last skin assessment, completed the day she was sent to the ER. She said the skin assessment completed by LVN A did reflect Resident #1 had bruising on her face and other injuries but there was no other description or sizing/measurements of the bruises. The DON stated her expectation was that she should have been notified when the first staff person recognized the fresh bruising to Resident #1's face and abrasions to her back. The DON stated staff should have numerous times to observe any resident injuries, such as when getting a resident up for breakfast, showering a resident and dressing them, They should have seen it. At any one of those times, it was an opportunity to see the injury and report it. If it didn't happen in the morning or overnight and when was it first noticed? <BR/>An interview with the ADM on 01/22/25 at 4:01 PM revealed Resident #1 did not have any black eyes or injuries that she had been made aware of. She stated if there were any black eyes or bruises, as the abuse/neglect coordinator, she should have been notified so that an investigation could be initiated. <BR/>On 01/22/25, after investigator intervention, the facility's ADM initiated a self-reported incident to HHSC and started a provider investigation into Resident #1's injuries of unknown origin.<BR/>An interview with MA D on 01/23/25 at 11:52 AM revealed she worked the morning and afternoon shift in the secured unit with Resident #1 on 01/18/25 but was not her main caregiver. MA D stated, I saw her face, like a dark part on the eye, her face looked bruised, but I had to call the nurse (LVN A) to look at her and he said he would call the family because she was not good. MA D described the injury she saw on Resident #1, it was there in the morning, she could not remember which eye, it looked like a black eye. MA D stated she did not know what happened to her eye and that was why when she saw it, she notified LVN A. MA D stated no one rounded with her when she came to work from the overnight shift, so she did not know how Resident #1 got the black eye. MA D stated if there was an injury on a resident, she was supposed to report it and she did, she notified the charge nurse. She stated, Because it wasn't looking fresh, I was thinking maybe something happened during the week, I was going to follow up. MA D stated the abuse/neglect coordinator was the ADM and she was supposed to be notified right away for any concerns and the ADM wanted to be notified about any form of abuse. <BR/>An interview with CNA E on 01/23/25 at 1:55 PM revealed the last time she remembered seeing Resident #1 was the morning of 01/16/25 when she helped the other CNA on the floor with Resident #1, and they cleaned her in the morning along with the nurse. All three of them saw her and at that time, CNA E stated she remembered seeing an eye injury on Resident #1, but she did not know what happened and could not remember what the injury looked like or where it was. CNA E stated she thought Resident #1's eyes looked black like she had fallen on something or something happened. She showered Resident #1 due to an incontinent episode and did not see any other injuries on her body. CNA E stated Resident #1 did not sleep a lot, liked to walk around all the time and pick things up and enter other people's room uninvited. The staff will tell her to sit down in a chair, but she will eventually get up and start walking, but CNA E had never seen Resident #1 fall. CNA E stated an injury of unknown origin was when a resident was found injured. When that occurred, the staff had to immediately report it to the charge nurse to they could assess and write an incident report. Same thing if a bruise was found on a resident, the charge nurse was to be notified and find out if any staff had already reported it, what happened, and give report to the next shift. If there was no incident in the system, then the current nurse on duty would need to follow up and find out what happened. CNA E stated, Maybe this person got injured and you do not report, something could happen. It is important if someone if injured. CNA E stated, I did not report the black eye on [Resident #1]. I was asking the nurse what happened to [Resident #1] I think I questioned it. But it wasn't something new, it was older, like the skin was becoming dark. When asked who the Abuse and Neglect Coordinator was at the facility, CNA E stated, Now I can't remember. <BR/>A follow up interview with the ADM and the DON on 01/23/25 at 1:57 PM revealed after looking at photos of Resident #1's facial bruising and back abrasions, the DON felt the one black eye was from the incident where the resident pulled a framed picture off the wall and hit her face. She also felt the resident may have been wearing glasses which could have caused the lighter yellow bruising across the bridge of her nose between her eyes. She said Resident #1 wore glasses, even though her MDS indicated she did not. The DON also felt the bruising could be a symptom of her advancing Huntington's and said spontaneous bruising could occur with the disease process. The DON stated, If I had seen the bruises, I would have reported it to the Abuse/Coordinator, and we would have followed the investigation for the State. The ADM stated she was the one to make the decision on if a resident's injury was suspicious, not the staff, but she must know about it first in order to investigate. The ADM stated staff had been in-serviced on if they see a bruise, not to assume it had been reported and to let someone know, and let me decide from there. <BR/>Record review of the facility's policy titled Abuse/Neglect, revised March 2018, reflected, .The facility will provide and ensure the promotion and protection of resident rights. It is each individual's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility .; Definition . 12. Injury of Unknown Source any injury to a resident where: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time; .C. Prevention: . 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect. The facility has in place a method to identify events such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse. All occurrences of potential abuse or criminal behavior will be investigated by the Abuse Preventionist and/or designee, D. Identification: The facility will identify and investigate events that may constitute abuse/neglect. The facility will determine the direction of the investigation based on a thorough examination of events. Opportunities to prevent abuse/neglect will be managed accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide pharmaceutical services (including the procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications and pharmacy services. <BR/>The facility failed to take Resident #1's blood pressure and administer her medication in accordance with the physician orders. Resident #1 was administered Propranolol (a beta blocker medication that relaxes blood vessels in the body is used to treat a variety of conditions including high blood pressure) three times a day from 12/01/24 through 01/18/25. The medication was only to be given if her blood pressure was over 110/60. However, there was no documented evidence to indicate her blood pressure was taken in her clinical record to validate the medication needed to be given and did not need to be held. <BR/>This failure could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and potential for decreased health status, including low and high blood pressure, falls, disorientation and physical discomfort. <BR/>Findings included:<BR/>Record review of Resident #1's Face Sheet dated 01/23/25 reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1's active diagnoses included hypertension (abnormally high blood pressure that is not the result of a medical condition), Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain that affects movement, cognitive functions, and emotions), dementia with mood disturbance (a decline in cognitive function with behavioral disturbances due to the progressive deterioration of brain cells), and repeated falls.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed her BIMS score was 05, which indicated severe cognitive impairment. She had unclear speech and sometimes understood others. Resident #1 had no signs or symptoms of delirium, no negative mood issues, no potential indicators of psychosis, no verbal or physically aggressive behaviors, and no rejection of care. Resident #1 had no range of motion of issues and used a wheelchair for mobility and she required substantial/maximum assistance for activities of daily living. <BR/>Record review of Resident #1's care plan dated 06/27/24 and last revised on 01/17/25 reflected she was at risk for falls due to her Huntington's diagnosis and had an unwitnessed fall on 01/13/25; however, there was no focus area reflected for her hypertension or related interventions. <BR/>Record review of Resident #1's January 2025 Physician's Orders reflected she was prescribed the beta blocker Propranolol 0.5mg three times a day for a diagnosis of hypertension (Start Date 06/27/24-open ended). The order also reflected, Hold for SBP&lt;110 and DBP &lt;60.<BR/>Record review of Resident #1's December 2024 and January 2025 MAR reflected she was administered the medication Propranolol every day she was at the facility from 12/01/24 through 01/18/25 with the exception of twice on 12/19/24 and once on the 12/20/24. The MAR also indicated under the name of the medication that it had parameters to be held if the blood pressure was 110/60.<BR/>Record review of Resident #1's vital records on the e-chart documented under the Vitals Tab reflected blood pressure readings only on 12/06/24, 12/13/24, 12/20/24, and 12/27/24. There were no blood pressure readings three times a day for Resident #1 from 01/01/25 through 01/18/25.<BR/>An interview with ADON B on 01/22/25 at 2:51 PM reflected she was in charge of overseeing the secured unit where Resident #1 lived, but all resident blood pressure audits were done by the other two ADONs. ADON B stated if there was an order for blood pressure to be taken prior to giving a medication, then the blood pressure should be taken. If it was not taken or if a resident refused or was moving too much to get an accurate reading, then the staff would need to notify the charge nurse so it could be documented. ADON B stated taking a resident's blood pressure was tied to their vitals parameters and if a medication for hypertension was given and the resident's blood pressure was already low, it could cause the resident to become unresponsive or sustain a fall. ADON B stated the blood pressure entry should be documented on the MAR with the medication. She stated when a MAR was being generated, the person generating it was responsible for ensuring the vitals parameter box was checked in order for it to show up and be placed on the MAR for staff to enter blood pressure readings. <BR/>An interview with MA D on 01/23/25 at 11:52 AM reflected she worked with Resident #1 the morning of 01/18/25 and worked a double shift from 7AM to 11PM. MA D stated she knew what the medication Propranolol was used for, and she gave it to Resident #1 routinely and crushed it into applesauce to feed it to her. MA D stated she took Resident #1's blood pressure reading each time before she gave the medication but there was not a place on the MAR to document it as the nursing staff had not added it to the document to record it. MA D stated she always assessed Resident #1 before giving her medications, which included taking her blood pressure. MA D stated she normally wrote those readings down on paper and kept it during her shift in case anyone, such as the MD or the NP came to the facility, and wanted to know what they were for the resident. MA D stated, But at the end of the day, I usually destroy it, but when I am work, I write it in case I need to prove it (taken the resident's blood pressure). MA D stated taking the residents' blood pressure was important because if the blood pressure was too low and a medication was given when it was supposed to be held, the resident might go into crisis, like a seizure, or if the blood pressure was too high, then steps needed to be taken to lower it. <BR/>An interview with the DON on 01/23/25 at 1:57 PM reflected that after state investigator intervention, the nursing management team went back and audited the resident's MAR and ensured all the MARs had corresponding vitals parameters (including blood pressure), if indicated, and in-serviced staff. The DON stated that even if the blood pressure was not on the MAR when it was generated, the medication aides as well as the nurses were capable of going in and revising the MAR and adding it . <BR/>Record review of the facility's policy titled, Medication Administration Procedures dated 2003 reflected, .13.When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. <BR/>The facility did not put a floor mat for Resident #1 as indicated in his care plan as an intervention in the resident's care plan who was a high fall risk while he was in his bed on 05/14/25. <BR/>This failure can put residents at risk for falls to sustain injuries due to not following interventions for fall precautions in place.<BR/>The findings included:<BR/>Record review of Resident #1 admission record dated, 05/14/25, revealed a [AGE] year-old male readmitted to the facility on [DATE]. His diagnoses included Unspecified Parkinsonism (a progressive nervous system disorder, which affects the ability to move muscles and muscle spasms or jerks), involuntary abnormal movements, cognitive communication problem, need for assistance with personal care, and prostate cancer.<BR/>Record review of Resident #1's quarterly MDS assessment, dated 02/08/25 revealed, Resident #1 rarely made himself understood, but he sometimes understood others. Resident #1 was dependent on staff for ADLs. Further the MDS revealed Resident #1 had a fall since admission and or reentry to the facility. MDS did not reflect BIMS.<BR/>Record review of Resident #1's care plan revised on 04/13/24 revealed Resident #1 had a high fall risk related to unsteady gait and lack of awareness. The goal was for Resident #1 to be free from minor injuries until the next review date. The interventions included fall mat at bedside. <BR/>Observation and interview with Resident #1 on 05/14/25 at 10:20 AM, revealed Resident #1 was in bed lying on his back, awake and attempting to climb out of bed. He had the call light within reach, his bed was in lowest position, and he was on a pressure relieving mattress with a pillow under both his knees. Resident #1 stated he was doing well. He said that he knew how to use the call light if he needed anything. Resident #1 did not have a floor mat next to his bed.<BR/>Observation and interview on 05/14/25 at 10:34 AM , revealed ADON went to storage room and took a floor mat and took it to Resident #1's room and placed it on the floor next to Resident #1's bed. The ADON said the CNA may have removed Resident #1's floor mat to get cleaned because it was dirty with food. He said the overnight shift will usually remove the mats in the morning to avoid them being a tripping hazard for the residents. The ADON said the expectation was that when the resident was in bed and he was a fall risk, the interventions for fall, needed to be flowed. He said he was going to do an in-service making sure that fall precautions are in place.<BR/>In an interview with CNA E on 05/14/25 at 10: 48AM, revealed she had put Resident #1 in bed when she noticed him falling asleep in the TV room. She said that she made sure that he had his call light, and his bed was in the lowest position. She said she did not see a floor mat in Resident #1's room this morning when she got Resident #1 up and when she put him in bed after breakfast. She said she was not aware that he required a floor mat because she hardly worked with Resident #1. She said the CNA that was familiar and usually worked with him had called in today. She said she should have asked his nurse if he required a floor mat. She said she checked on residents that are known to be fall risks frequently and kept their doors open so that any staff passing by can see them if they are trying to get out of bed without calling and assisting them . She said the floor mat as a fall intervention, would help to cushion Resident #1 if he fell out of bed. She said the risk to the resident was if he fell, he would hit the floor and hurt himself.<BR/>In an interview with LVN F on 05/14/25 at 10:37 AM, she said she was Resident #1's nurse and CNA E was assigned to him today. She said she did not work on Monday; therefore, she does not know what happened to Resident #1's floor mat. <BR/>She said the floor mat was a fall intervention required for Resident #1 and should be in place. She said floor mats can be a tripping hazard so the CNAs usually will remove them when helping the residents out of bed or when caring for them in bed.<BR/>In an interview with DON on 05/14/25 at 2:09 PM, it was revealed Resident #1 had a lot of interventions for fall in place including being moved from the secure unit so that he could be closer to the nursing station for quick response and availability to staff. She said the floor mat was part of his fall precaution and the expectation was that when Resident was in bed, it should be on the floor next to his bed. She said it was possible someone moved it out of the way while providing care. <BR/>In an interview with the ADM on 05/14/25 at 4:40 PM, she expected staff to provide interventions as needed, as scheduled, or as requested and to document what was provided. <BR/>Record review of facility policy titled Preventive Strategies to Reduce Fall Risk revision date 10/05/16 reflected:<BR/>Policy: The goal of fall prevention strategies is to design interventions that minimize fall risk by<BR/>eliminating or managing contributing factors while maintaining or improving the resident's mobility.<BR/>8. Education: . Do not assume that individuals can figure out these things by themselves . Educate family members about safety measures and fall prevention. Provide instruction on how to identify risk and environmental hazards. Document education.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.<BR/>The facility failed to ensure that the food items in the refrigerator were dated, labeled, and sealed appropriately. <BR/>These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. <BR/>Observation on 09/13/2022 at 9:30 a.m. during the initial tour of the small kitchen revealed Food items not dated: 1 undated bread rack that stored facility supply of bread. Further observation revealed one staff personal backpack sitting on bread rack with bread. Two blue Safe Ice Scoop caddies in the small kitchen near entrance door and over the dishwasher contained dead roaches and brown specs and particles of roach feces. <BR/>Upon observation of the small kitchen #1's Dairy Refrigerator A foul odor was detected reminiscent of spoiled foods/dairy, with a brown sticky residue noted to be spilled and dried up around the base of refrigerator.<BR/>Observation and interview with the DM on 09/13/22 AT 9:30 AM of Refrigerator located off from the main kitchen revealed 3 trays of undated thickened liquids, 3 medium size boxes of corn, undated, on shelf defrosting. DM stated that items quality could diminish in the freezer if left unsealed.<BR/>Additional observation conducted with the DM revealed the facility's freezer contained opened, unsealed, undated/unlabeled perishable foods including 1 package of unboxed, undated open meatballs, and an observation of meatballs that had spilled out of the clear package on to the floor and shelves below. 1 open package of chicken patties and 1 open box of hamburger patties not dated. 1 chicken patty on the floor of freezer unpackaged with other spilled particles of crumbs and food.1 box of corn with the top and bag opened and not sealed. 5 boxes of corn on the shelf to the left undated.<BR/>Observation of refrigerator #3 with the DM on 09/13/2022 at 9:38 a.m. revealed undated and labeled foods ,1 cart with approximately 3 rows of desserts were observed undated and labeled and 1 cart of dessert pie uncovered in the kitchen area.<BR/>Observation on 09/13/2022 at 9:45 a.m. of the cook prep and steam table in the main kitchen revealed 1 large staff peach purse and coffee mug under steam table with kitchen prep tools for serving and trays. 1 metal coffee mug placed on top tray of steam table.<BR/>Observation of 09/13/2022 at 9:48 a.m. the handwashing sink in the kitchen revealed paper towel not working and no additional towels for staff to dry hands. <BR/>In an interview the DM on 09/13/2022 at 9:45 a.m. revealed that DM stated that housekeeping routinely brings paper towels to access until dispenser was repaired, and that paper towels should be available to prevent cross contamination after cleaning your hands. DM said that housekeeping had not brought paper towels yet. He stated that he did not contact housekeeping to request paper towels. He stated that it was important to practice good sanitary practices and that he would go and get paper towels. Upon returning to the kitchen for lunch temps, there were no paper towels. and the staff were working on their second meal prep for the day.<BR/>Observation on 09/13/2022 at 11:30 a.m. revealed the kitchen staff resealed and dated of the opened items in the freezer instead of discarding due to exposure. Paper towel dispenser still not working no paper-towels to dry hands after handwashing.<BR/>Interview on 09/13/2022 at 10:10 a.m. with DM he stated that the paper towel dispenser was not working and there were no paper towels observed for staff and guest to dry hands after washing. The DM stated that the housekeeping staff were bringing paper towels for the kitchen staff to use to dry their hands, however at the time of the observation there were no paper towels. Upon returning to the kitchen at 11:45 a.m. there were no paper towels observed for handwashing. He stated that he notified the Maintenance Director (MD) verbally that the machine was not working and to come and repair. DM stated that the boxes that were in the refrigerator were defrosting, he did not say why they weren't labeled. He stated that desserts were just made this morning, so they were fresh. At that time kitchen aid was observed washing her hands and sticking her fingers up in the dispenser to pull down paper towels, touching the machine, therefore hands were decontaminated. <BR/>During an interview with the DM on 09/13/2022 at 2:55 p.m. revealed that if staff are not sealing packages, dating, cleaning hands, this could affect the residents health and they could get sick. He stated that if the packages were open he would need to discard, as the food had been exposed and when foods were unsealed and undated the kitchen staff would not be able to determine when the food was delivered, open, or ready to discard timely. <BR/>Interview on 09/13/2022 10: 15 a.m. with Maintenance Director (MD) revealed that he had not been notified that the kitchen paper towel dispenser needed to be repaired, and he stated that he did not receive a work order for repairs. <BR/>Review of maintenance request LOG? on 9/13/2022 upon request revealed no documentation of a work order to be repair paper towels. <BR/>Interview with the [NAME] on 09/13/2022 at 12:00 pm revealed that she did not observe the meatballs that spilled in the freezer, and that she takes the entire box to the prep area and cook. She stated that she did not observed food on the floor of the freezer. She stated that boxes should be dated and sealed appropriately to prevent food being cooked that has been contaminated. <BR/>Observation on 09/14/2022 at 8:25 a.m. on the (TCU) Transitional Care Unit of the facility revealed a kitchenette located adjacent to the nursing station that had a brown liquid splatter of liquid substance under the sink, open flake cereal undated and sealed, and a gallon of orange juice located in the refrigerator uncovered. <BR/>Interview with CNA-V on 09/14/2022 8:35 a.m. revealed that the cereal stored in the kitchenette area was for resident to eat if they were hungry after hours. She stated that the kitchen brings snacks for the residents to eat before leaving the facility at 8:00 p.m.<BR/>Interview with LVN-E on 09/14/2022 8:45 a.m. revealed that she was working on the unit and that the kitchen provided snacks for the residents to eat, and they were in the room behind the nursing station. <BR/>Interview on 09/14/2022 at 9:09 a.m. with Lead Dietary Manager revealed that he had posted a sign on the TCU unit that health care staff must not store food and drinks in the small refrigerator or pantry areas, due to food regulations prior to leaving the Dietary position. He stated that he would remove all the food located in that kitchenette and notify the DON that food should not be kept in the refrigerator and kitchenette area for residents, and the kitchen staff could not monitor and assure residents were receiving food services consistent with facility guidelines for safe and sanitary conditions. <BR/>In an interview with the Senior Dietary corporate manager on 09/14/2022 at 9:30 a.m. he revealed that the food that was observed on the TCU hall undated and unsealed could lead to exposure of bacteria and illness for the residents. He stated that he previously educated the nursing staff and placed signs for food not to be kept in the TCU cabinets and refrigerator, because all foods need to be kept according to the dietary food procedures for preserving the quality and determining the proper storage quality by dating and sealing. He stated that he would be sending a staff from the kitchen down immediately to remove all food and place a sign on the cabinets and personal refrigerator.<BR/>Record review of Facility policy titled Refrigerated Storage, Dated August 1, 2012, and revised 06/01/2013 FSM-IV-007 POLICY: It is the policy of this facility to store, prepare, and serve foods in accordance with federal, state, and local sanitary codes. PROCEDURE: As a variety of foods are stored under refrigeration, it is essential that refrigerator temperatures be low enough to safely keep the most perishable foods. Refrigerator temperatures that are consistently 38&deg;F or below will provide this safety margin. If it is necessary to store fresh and cooked food in the same refrigerator, the cooked foods should be covered, dated, and labeled and stored above the fresh foods. If it is necessary to store fresh and cooked food in the same refrigerator, the cooked foods should be covered, dated, and labeled and stored above the fresh foods. All foods will be properly wrapped and/or stored in sealed containers and dated and labeled, it is the policy of this facility to maintain equipment, work surfaces, walls, and floors in sanitary condition through daily, ongoing procedures. Formal sanitation inspection in the food service department occurs on a frequent basis. Informal sanitation inspections occur daily.<BR/>FOODBORNE ILLNESS Retail Food Protection | FDA.: <BR/>Food code 2017 Professional Standards Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially preschool age children, older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening. Epidemiological outbreak data repeatedly identify five major risk factors related to <BR/>employee behaviors and preparation practices in retail and food service establishments <BR/>as contributing to foodborne illness: <BR/>o Improper holding temperatures, <BR/>o Inadequate cooking, such as undercooking raw shell eggs, <BR/>o Contaminated equipment, <BR/>o Food from unsafe sources, and <BR/>o Poor personal hygiene <BR/>The Food Code addresses controls for risk factors and further establishes 5 key public health interventions to protect consumer health. Specifically, these interventions are: <BR/>demonstration of knowledge, employee health controls, controlling hands as a vehicle of contamination, time, and temperature parameters for controlling pathogens, and the consumer advisory. The first two interventions are found in Chapter 2 and the last three in Chapter 3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 5 of 9 residents (Residents #1, #2, #7, #8, #9) reviewed for environment. <BR/>The facility failed to ensure Residents #1, #2, #7, #8, and #9 had hot water for washing and bathing in their rooms.<BR/>This failure affected residents by placing them at risk for a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes.<BR/>In an observation of Resident #1's bathroom on 1-20-2024 at 4:40PM, it was discovered that Resident #1 did not have hot water in her bathroom. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that there wasn't hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of assistance with ADL. <BR/>In an observation of Resident #2's bathroom, on 1-20-2024, at 5:00 PM, it was confirmed that Resident #2 had no hot water in her bathroom. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia, and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis. <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was conveyed that Resident's bathroom hasn't had hot water for weeks. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>In an observation of Resident #7's bathroom, on 1-20-2024, at 5:20 PM, it was confirmed Resident #7's bathroom was without hot water. <BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 has a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8 stated his room hasn't had hot water for over a week. <BR/>In an observation of Resident #8's bathroom, on 1-20-2024, at 5:20PM, it was revealed that Resident #8 did not have hot water in his bathroom. <BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 has a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism, unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room hasn't had hot water for over a week. <BR/>In an observation of Resident #9's bathroom, on 1-20-2024 at 6:10 PM, it was confirmed that Resident #9 had no hot water in his bathroom. <BR/>In an interview with the Director of Maintenance by phone, it was revealed he is offsite up north. The Director of Maintenance said there was hot water in the lines, but he thinks the mixing valve is defective, which could be causing the water, in the 300 area, to not be hot in the resident's rooms. However, he was not sure if that was the problem. The Director of Maintenance said they were waiting on a part to come in Monday to see if that fixes the problem. The Director of Maintenance stated that the water temperature has dropped below 102 degrees Fahrenheit, in the line, but not over 2 weeks. The Director of Maintenance would not say how long the water temperature has been a problem. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was revealed that his expectation was that residents have hot water in their bathrooms. The Administrator stated that one of their tankless water heaters had to be replaced and the control valve that adjusts the heat wasn't working. The Administrator stated that a part has been ordered and should be at the facility next week. The Administrator said was the Director of Maintenance's responsibility to ensure residents have hot water in their bathrooms. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was learned that her expectation was that residents be taken to units that do have hot water to use. The DON stated that when residents do not have hot water in their restrooms, it could be an infection control issue. The DON said the facility had a problem with hot water in the 300-room domain. The DON stated it was everyone's responsibility to make sure residents have hot water and report it when residents don't. <BR/>Record Review of the facility's undated Hot Water Systems Policy stated the hot water system will be checked daily to include shower temperatures. The water temperatures should be maintained at 100 degrees Fahrenheit minimum .<BR/>13.Temperature readings will be recorded on the water temperature log. <BR/>14. <BR/>The hot water tanks should be adjusted accordingly with readings that are too high or too low. Adjustments will be noted on the water temperature log.<BR/>15. <BR/>After adjustments are made, the temperature must be rechecked within thirty minutes of the adjustment. If the water continues to be too hot or too cold, the Administrator should be notified immediately.<BR/>16. <BR/>The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) level 1 residents with mental illness were provided with a PASARR level 2 evaluation for 7 of 10 residents (Resident #104, Resident #82, Resident #5, Resident #14, Resident #21, Resident #64's, and Resident #76), reviewed for resident assessment.<BR/>Resident #104, Resident #21, Resident #64, and Resident #76 PASARR's level 1 screening form did not reflect mental illness and the residents did not have a PASARR level II evaluation.<BR/>Resident #82 was not referred to the Local Mental Health Authority (LMHA) for PASARR Level 2 screening.<BR/>Resident #5 and Resident #14 did not have a PASARR level 1 or 2 evaluation completed.<BR/>These failures could place residents at risk of not receiving necessary specialized services to meet their individual needs.<BR/>The findings were:<BR/>Resident #104<BR/>Record review of Resident #104's quarterly MDS assessment, dated 08/17/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 5 indicating the resident's cognition was severely impaired. Her diagnoses included schizophrenia, psychotic disorder, depression, and non-Alzheimer's dementia. <BR/>Record review of Resident #104's Care Plans reflected:<BR/>*04/05/23: The resident was receiving services to assist with her diagnosis of schizophrenia.<BR/>*12/12/23: The resident had behaviors which included paranoid delusions that a substance was coming through the walls and getting in her blood stream and others were out to get her through the technology in the building and was fearful for her safety.<BR/>Record review of Resident #104's PASARR level 1 screening, dated 07/28/23, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. <BR/>Record review of Resident #104's Electronic Health Record revealed no PASARR level 2 evaluation was completed.<BR/>An interview on 12/10/24 at 1:54 PM with the DON revealed she did not know why Resident #104 had a negative PASARR Level 1 screening. She said the MDS staff were responsible for checking for accuracy and the resident was at risk of not receiving services she could qualify for. <BR/>An interview on 12/10/24 at 2:17 PM with MDS Nurse G revealed he did not know why Resident #104 had a negative PASARR level 1 screening. He said that PASARR level 1 screening forms were only reviewed if the resident went to the hospital and returned. He said the resident was at risk of not having correct care and management with a negative PASARR level 1 screening. <BR/>Resident #82<BR/>Review of Resident #82's MDS assessment completed on 11/14/24, reflected he was a [AGE] year-old male with an original admission date of 3/16/2019, and a re-entry admission date of 10/01/2020. He had a BIMS score of 13 with the following diagnoses: Schizophrenia, Seizure Disorder, Anxiety Disorder, Depression, Psychotic Disorder (Other than schizophrenia). <BR/>Record review of Resident #82's PASSR Level 1 screening was completed by the facilities MDS nurse on 7/29/2023. The screening indicated yes to question: Is there evidence or an indicator that this is an individual that has a Mental Illness? <BR/>Record review of Resident #82's Care Plan reflected the last Care Plan Reviewed was completed on 12/04/2024 stated:<BR/>Resident #82 has MI (mental illness) is PASARR positive.<BR/>Resident #82 will have the specialized services recommended by local authority (LA) per PASARR Specialized Services program as needed. <BR/>The LA will be invited annually to the care plan meeting for review of Specialized Services.<BR/>During an interview on 12/10/2024 at 2:00 p.m., MDS Nurse G stated he was unable to confirm if Resident #82 was referred to the Local Mental Health Authority (LMHA) for PASARR Level 2 screening. The MDS Coordinator stated there was no record of the screening occurring. The MDS coordinator stated it usually does not take over a year to get a screening, he stated it will usually take 2-3 weeks to get the PASSR Level II screening. <BR/>During an interview on 12/10/2024, Facility Social Worker (SW) reported there was a meeting with the LMHA interdisciplinary Team (IDT) coordinator today. The SW reported she was told by the IDT coordinator that the LMHA did not have any record of Resident #82. <BR/>Resident #5 <BR/>Record review of Resident #5's quarterly MDS assessment, dated 11/10/24, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 14 indicating the resident's cognition was intact. Her diagnoses included unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. <BR/>Record review of Resident #5's Care Plans reflected:<BR/>*07/14/21: The resident was receiving services to assist with her diagnosis of anxiety.<BR/>*12/28/22: The resident had behaviors which included refusing to be weighed, not allowing assist with ADL's, not allowing staff to assist with Nebulizer therapy, not allowing staff to assist with O2 therapy, non-compliant with changing out equipment ie: tubing, mask, and humidifiers and ordering supplies from outside venders. not allowing room to be cleaned, not being compliant with ordered diet, refusal to throw trash away, hoarding items brought in from the outside as well as from the other residents in the facility and refusing therapy services at times.<BR/>Record review of Resident #5's Electronic Health Record revealed no PASARR level 1 or 2 evaluation was completed.<BR/>An interview on 12/10/24 at 3:45 PM with MDS Nurse H stated the resident was at risk of not having correct care and management without a PASARR level 1 screening. <BR/>An interview on 12/10/24 at 4:43 PM with the DON revealed she did not know why Resident #5 PASARR Level 1 screening was not completed. She said the MDS staff were responsible for checking to make sure they had one completed and the resident was at risk of not receiving services she could qualify for. <BR/>Resident #14 <BR/>Record review of Resident #14's quarterly MDS assessment, dated 08/17/24, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 12 indicating the resident had moderate cognitive impairment. Her diagnoses included alcohol dependence with alcohol-induced persisting dementia, schizophrenia, unspecified, major depressive disorder, single episode unspecified, unspecified psychosis not due to a substance or known physiological condition. <BR/>Record review of Resident #14's Care Plans reflected:<BR/>*08/22/22: The resident was receiving services to assist with her diagnosis of anxiety.<BR/>Record review of Resident #14's Electronic Health Record revealed no PASARR level 1 or 2 evaluation was completed.<BR/>An interview on 12/10/24 at 3:45 PM with MDS Nurse H stated the resident was at risk of not having correct care and management without a PASARR level 1 screening. <BR/>An interview on 12/10/24 at 4:43 PM with the DON revealed she did not know why Resident #14 PASARR Level 1 screening was not completed. She said the MDS staff were responsible for checking to make sure they had one completed and the resident was at risk of not receiving services she could qualify for. <BR/>Resident #21<BR/>Record review of Resident #21's quarterly MDS assessment, dated 11/20/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 15 indicating the resident's cognition was intact. Her diagnoses included depression, psychotic disturbance, mood disturbance, and anxiety. <BR/>Record review of Resident #21's Care Plans reflected:<BR/>*05/04/22: The resident was receiving services to assist with her diagnosis of depression.<BR/>*09/23/24: The resident had behaviors which included accusatory towards others (staff) and refusal of therapy.<BR/>Record review of Resident #21s PASARR level 1 screening, dated 09/15/23, reflected the resident had a serious mental illness. <BR/>Record review of Resident #21's Electronic Health Record revealed no PASARR level 2 evaluation was completed.<BR/>An interview on 12/10/24 at 3:45 PM with MDS Nurse H revealed he did not know why Resident #21 did not have a PASARR level 2 evaluation. He said that PASRR level 1 screening forms were only reviewed if the resident went to the hospital and returned. He said the resident was at risk of not having correct care and management with a positive PASRR level 1 screening. <BR/>An interview on 12/10/24 at 4:43 PM with the DON revealed she did not know why Resident #21 did not have a PASARR Level 2 evaluation. She said the MDS staff were responsible for checking for accuracy and the resident was at risk of not receiving services she could qualify for. <BR/>Resident #64<BR/>Record review of Resident #64's quarterly MDS assessment, dated 07/26/24, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The resident's BIMs score was 15 indicating the resident's cognition was intact. His diagnoses included depression, anxiety, and schizophrenia. <BR/>Record review of Resident #64's Care Plans reflected:<BR/>*08/14/22: The resident receives frequent counseling sessions. <BR/>*08/19/22: The resident was receiving services to assist with his diagnosis of schizophrenia.<BR/>Record review of Resident #64's PASARR level 1 screening, dated 08/01/23, reflected the resident had a serious mental illness. <BR/>Record review of Resident #64's Electronic Health Record revealed no PASARR level 2 evaluation was completed.<BR/>An interview on 12/10/24 at 3:45 PM with MDS Nurse H revealed he did not know why Resident #64 did not have PASARR level 2 evaluation. He said that PASARR level 1 screening forms were only reviewed if the resident went to the hospital and returned. He said the resident was at risk of not having correct care and management with a negative PASRR level 1 screening. <BR/>An interview on 12/10/24 at 4:43 PM with the DON revealed she did not know why Resident #64 did not have a PASARR Level 2 evaluation. She said the MDS staff were responsible for checking for accuracy and the resident was at risk of not receiving services she could qualify for. <BR/>Resident #76<BR/>Record review of Resident #76's quarterly MDS assessment, dated 11/06/24, reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The resident's BIMs score was 11 indicating the resident has moderate cognitive impairment. His diagnoses included schizophrenia, psychotic disorder, mood disturbance, anxiety, depression, and unspecified dementia. <BR/>Record review of Resident #76's Care Plans reflected:<BR/>*08/13/24 The resident will identify strengths, positive coping skills.<BR/>*08/13/24: The resident was receiving services to assist with his mood diagnosis.<BR/>Record review of Resident #76's PASARR level 1 screening, dated 12/22/23, reflected the resident did not have a serious mental illness and serious mental illness was checked as no. <BR/>An interview on 12/10/24 at 3:45 PM with MDS Nurse H revealed he did not know why Resident #76 had a negative PASRR level 1 screening. He said that PASARR level 1 screening forms were only reviewed if the resident went to the hospital and returned. He said the resident was at risk of not having correct care and management with a negative PASARR level 1 screening. <BR/>An interview on 12/10/24 at 4:43 PM with the DON revealed she did not know why Resident #76 had a negative PASARR Level 1 screening. She said the MDS staff were responsible for checking for accuracy and the resident was at risk of not receiving services she could qualify for. <BR/>Review of the facility policy, PASARR Maintenance in the Active Paper Medical Record, dated January 2018, reflected:<BR/> .If the Residents is PASARR positive the following forms will follow:<BR/>LA (Local Authority) PASARR Evaluation (PE) Form for all confirmed Negative or Positive PE Forms. (Obtained from the LA).<BR/>LA 1014 or Individual Service Plan (ISP) Forms. (Obtained from the LA).<BR/>IDT Meeting (Printed from Simple LTC along with any handwritten notes or the handwritten IDT form prior to data entered and submitted to Simple LTC)<BR/>LA PSS (PASARR Specialized Service) (if applicable) .<BR/>Resident #5<BR/>PASARR <BR/>12/10/24 11:50 AM <BR/>Interview with social worker [NAME] stated she does not complete PASARRs, she only does PASARRs for residents that are transferred to another facility.<BR/>What medications do you get and why do you need to take them? Lorazepam for anxiety, Quetiapine Fumarate antipsychotic,trazodone for depression and bupropion for depression<BR/>Did you have this diagnosis/condition prior to your admission to this facility? yes<BR/>Do you receive any specialized services to help with your mental health or disability concerns? yes <BR/>What are they doing to address your mental health or disability concerns? take medications and see a psychiatrist.<BR/>No PASARR on file<BR/>Resident #14<BR/>PASARR <BR/>12/10/24 01:45 PM <BR/>Resident HOH unable to answer questions<BR/>No Pasarr on file<BR/>Resident #21<BR/>PASARR <BR/>Resident #64<BR/>PASARR <BR/>12/10/24 01:02 PM <BR/>Can you tell me about your current diagnosis/condition? Anxiety, depression, bipolar, adhd<BR/>Did you have this diagnosis/condition prior to your admission to this facility? bipolar was diagnosed after admission. Do you receive any specialized services to help with your mental health or disability concerns? counseling<BR/>What are they doing to address your mental health or disability concerns medication and counseling<BR/>Resident #76<BR/>PASARR <BR/>12/09/24 10:21 AM <BR/>RR revealed PASSAR 1 completed. Resident has a diagnosis of Schizophrenia. No PASSAR II on file.<BR/>Resident #82<BR/>PASARR <BR/>12/09/24 10:22 AM PASSR I completed, no record of PASSR II - resident has diagnosis of psychiatric/Mood Disorder Anxiety Disorder, Depression (other than bipolar), Bipolar Disorder, Psychotic Disorder (other than schizophrenia) Schizophrenia<BR/>12/10/24 11:47 AM Social Worker [NAME] - She does PASSR 1 when a resident is sent out to another facility. That is all of her capacity in dealing with PASSR. <BR/>12/10/24 02:00 PM Benga Fasusirn, MDS Coordinator, also does PASSR for residents. In looking at MDS for this resident, when a resident comes to facility, review PASSR and if anything showing mental, IDD, etc. he will let social worker know, then they send a list of those to Metro Care. Then Metro Care will set up an appointment. He does not know the duration of time, it depends on the metro care. The social worker will follow up with Metro care if meeting is not completed. <BR/>When resident comes in with PASSR, complete in Simple he enters the information. If it is triggered for PASSR 2, he will let social worker know to contact Metro. How do you contact SW? <BR/>Regarding Mr. [NAME] - IDT has been scheduled, [NAME] from Metro Care will send the appointment info. Should it have already occurred? He could not tell you the date of PASSR level 2 screening. <BR/>The lady IDT was here today and said it was scheduled, his was done in July 2023, he said it doesn't usually take this long. It usually takes 2-3 weeks. <BR/>He cannot answer why it has taken over a year to get level 2 PASSR. <BR/>Can you confirm that metro was notified that they were notified he was triggered, it is up to the social worker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers.<BR/>The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled.<BR/>This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes. <BR/>Record Review of Resident #1's Social Service Quarterly Assessment, dated 1-18-2024 revealed a BIMS Score of 13 which indicated little to no cognitive impairment and required extensive assistance with ADLs to include feeding assistance and impaired vison. <BR/>Record Review of the shower log, in the 300-domain area, for Resident #1 revealed the last time Resident #1 took a shower was 12/26/2023. There were no other shower entries for Resident #1 from 12-27-2023 through 1-20-2024. <BR/>In an interview with Resident #1, on 1/20/2024, at 1:12 PM, revealed that Resident #1 had not had a shower in 3 weeks. Resident #1 stated she wanted to take a shower at least once a week. <BR/>Record review of Resident #5's Face Sheet dated 1-20-2024, showed an [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #5 had a primary diagnosis of pneumonia unspecified organism, chronic atrial fibrillation unspecified (the heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles)), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and reduced mobility. <BR/>Record Review of the facility's ADL Dependent Resident Report dated 1-20-2024, indicated Resident #5 was an ADL Dependent Resident of the facility and needs assistance bathing. <BR/>In an interview with Resident #5, on 1/20/2024, at 4:10 PM, it was conveyed that Resident #5 needed ADL assistance as she loses her balance. Resident #5 revealed she had not been bathed as often as she wanted to. Resident #5 wanted to get showered at least twice a week. Resident #5 stated that she had gone over a week without getting a bed-bath. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that the showers in the 300-domain hall, has not had hot water. Resident #2 conveyed that she has not had a shower in 3 weeks and there has not been hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of ADL assistance. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis (a condition in which too much acid accumulates in the body). <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was expressed that the Resident's bathroom had not had hot water for weeks and Resident #7 had not had a shower for over a week or two. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>Record review of the shower log for Resident #7 disclosed that Resident #7 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 had a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8's room had not had hot water for over a week and Resident #8 had not had a shower in a week or two. Resident #8 would like to get a shower every couple of days.<BR/>Record review of the shower log for Resident #8 disclosed that Resident #8 had not had a shower or bath from 1-1-2024 through 1-20-2024.<BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 had a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism (a disorder of the central nervous system that affects movement), often including tremors., unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room had not had hot water for over a week and Resident #9 had not had a shower in over a week. Resident #9 stated that he would like to have a shower every other day and he did not want to take a cold shower. <BR/>Record Review of the shower log for Resident #9 indicated Resident #9 refused a shower on 1-18-2024. There were no other shower logs for Resident #9 for the year of 2024. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was disclosed that his expectation was that residents were offered showers in other units, even if their unit, does not currently have hot water. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was revealed that her expectation was that a staff members would take a resident to another unit to get a shower, if the resident's unit does not have hot water. The DON stated that staff, in the 300 unit, where the hot water was temporarily out, have been instructed to take residents, who want a shower, to another unit. The DON stated that it was her expectation that staff did not offer a cold shower to a resident if there is a shortage of hot water. <BR/>Record Review of the facility's undated Bath, Tub/Shower Policy stated .The frequency and type of bathing depends on resident preference, skin condition, tolerance, and energy level. Although a daily bath or shower is preferred and necessary for some, the aging skin can be maintained by bathing every two days or with partial bathing as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed ensure that a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possibleto for 1 (Resident #104) of 4 residents reviewed for incontinence care. <BR/>1. CNA D failed to clean Resident #104's peri-area during incontinence care provided on 12/08/24.<BR/>These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.<BR/>The findings included: <BR/>1. Record Review of Resident #104's quarterly MDS assessment, dated 08/17/24, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 5 indicating the resident's cognition was severely impaired. The resident was dependent on staff for all personal hygiene. The resident was always incontinent of bowel and bladder. Her diagnoses included non-Alzheimer's dementia, muscle weakness, and lack of coordination. <BR/>Record review of Resident #104's Care Plans, revised 04/08/24, reflected the resident had an ADL self-care performance deficit and required assistance by one staff with personal hygiene. The resident required assistance by staff for toileting.<BR/>An observation on 12/08/24 at 1:03 PM revealed Resident #104 was in bed. She was awake, alert, and non-verbal. CNA D entered the room to provide incontinence care. The resident's brief was soiled with bowel movement and urine. CNA D folded down the resident's brief. CNA D used toilet paper and wipes to clean the peri-area and vagina. There was a large amount of bowel movement present. CNA D did not clean all of the bowel movement from the resident's peri-area. The resident was turned to her left side and CNA D used toilet paper and wipes to clean the bowel movement from the buttocks. CNA D pulled out the soiled brief. CNA D changed gloves but did not perform hand hygiene. CNA D bagged the dirty laundry, removed his gloves and performed hand hygiene. CNA D donned new gloves. CNA D laid down a new brief and put it on the resident. The resident's peri-area area was still soiled with bowel movement. CNA D covered the resident's peri-area with the brief. CNA D was about to fasten the resident's brief. The Surveyor asked CNA D if he was going to finish cleaning the resident. CNA D left the room and said he was going to get more help. CNA D returned with CNA E. CNA E said she was not taking over incontinence care for the resident, but she was there to assist CNA D. CNA D said he was new to the facility but had been a CNA since 2016. CNA D donned gloves and folded down the new brief and began cleaning and wiping the peri-area and vagina with wipes. CNA E told CNA D to be gentle. CNA D cleaned the bowel movement off the vagina and peri-area. CNA D changed gloves but did not perform hand hygiene. CNA D put on new gloves, rolled the resident to her side, and cleaned the resident's buttocks again. CNA D removed the soiled brief. CNA D did not change gloves or perform hand hygiene. CNA D put a new brief on the resident and removed his gloves. He did not perform hand hygiene and proceeded to turn and reposition the resident with no gloves. CNA E told CNA D that the resident needed more linen. CNA D left the room and returned with more linen. CNA D put on new gloves but tore his right glove. CNA D did not change gloves to apply the fresh linen. CNA D removed gloves and picked up the soiled linen bag and the soiled trash bag with his bare hands and left the room.<BR/>An interview on 12/08/24 at 2:10 PM with CNA D revealed he did not thoroughly clean Resident #104's peri-area. He said he did not clean all of the bowel movement because he said maybe he did not see it because his peripheral vision was bad. He said if he did not thoroughly clean the resident, then she could get a bacterial infection. CNA D said he started working at the facility on 09/28/24 and said he was going to be checked off on incontinence care on 12/08/24. He said his training included 2-3 days of training with another staff. CNA D said he was not supposed to wear torn gloves and he was supposed to preform hand hygiene when changing his gloves. He said hand hygiene was important to prevent spreading feces, urine, flu, and COVID.<BR/>An interview on 12/09/24 at 3:34 PM with LVN F revealed she was the infection preventionist. She said for staff doing incontinence care, they needed to change gloves and do hand hygiene when going from dirty to clean. She said there was a risk of infection if hand hygiene was not performed. She said she did an incontinence care check-off for CNA D on 12/08/24 and he passed after two tries. <BR/>An interview on 12/10/24 at 1:56 PM with the DON revealed CNA D had to do a return demonstration check for incontinence care before he could return to working. She said staff were supposed to change their gloves when going from dirty to clean areas and they were not supposed to wear torn gloves. The DON said staff were supposed to use gloves to remove trash. She said she was not aware that CNA D said he had problems with his vision. The DON said the resident was at risk for infection if she was not cleaned thoroughly. The DON said there was a risk of infection when staff did not change gloves and perform hand hygiene. <BR/>Record review of the facility's Peri-Care Audit Tool, not dated, reflected CNA D was checked of on incontinence care and hand hygiene on 08/29/24 and 12/08/24. <BR/>Record review of the facility's policy, Nursing Assistant Clinical Skills Checklist and Competency Evaluation, dated February 2019, reflected:<BR/>Provides Perineal Care (Peri-Care) for Female<BR/>4. Puts on clean gloves before washing perineal area.<BR/>5. Places pad/linen protector under perineal area including buttocks before washing.<BR/>6. Exposes perineal area (only exposing between hips and knees).<BR/>7. Applies soap to wet washcloth.<BR/>8. Washes genital area, moving from front to back, while using a clean area of the washcloth for each stroke.<BR/>9. Using clean washcloth, rinses soap from genital area, moving from front to back. while using a clean area of the washcloth for each stroke.<BR/>10. Dries genital area moving from front to back with dry cloth towel/washcloth. <BR/>11. After washing genital area, turns to side, then washes rectal area moving from front to back using a clean area of washcloth for each stroke .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received food prepared in a from designed to meet individual needs for one (Resident #6) of 3 residents reviewed for nutrition services. <BR/>The facility failed to ensure the lunch meal served to Resident #6 on 12/08/24 had the appropriate consistency for the meat serving for the mechanical soft diet.<BR/>The deficient practice could affect residents who received mechanical soft meals from the kitchen by contributing to choking, poor intake, and/or weight loss.<BR/>The findings included:<BR/>1. Record review of Resident #6's annual MDS assessment, dated 11/13/24, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 13 which indicated his cognitive status was intact. The resident required supervision for eating. His diagnoses included difficulty swallowing and respiratory failure. The resident required a mechanically altered diet. <BR/>Record review of Resident #6's care plans, dated 08/29/24, reflected he was on a mechanical diet. Facility interventions included: Determine food preferences and provide within dietary limitations.<BR/>Encourage meal completion and document amount consumed.<BR/>Monitor weight per facility protocol.<BR/>An interview on 12/08/24 at 11:10 AM with Resident #6 revealed he was awake, alert, and oriented. He was laying in bed. He said he had problems chewing his food. He said the vegetables were not soft and he needed his meat to be ground up. He said he did not have enough strength to chew meat that was chopped instead of ground. <BR/>An observation on 12/08/24 at 1:35 PM revealed Resident #6 was finishing his meal. He said he was not able to eat the meat. The meat was still on his plate and was in big chunks on his plate. It was not finely chopped or ground. The resident's meal ticket said he was on a mechanical soft diet. <BR/>An interview on 12/08/24 at 2:33 PM with the Dietary Manager revealed the meat served on the lunch meal tray for 12/08/24 was pot roast. She said the mechanical soft diet should have had ground pot roast. The Dietary Manager said with Resident #6 he did not like his hamburgers to be ground up. She said she had spoken to him before about his meals. She said she did not realize the resident was not able to eat his pot roast because it was not ground up. The Dietary Manager said it was important for the meat to be served the right texture so that the resident would not choke or aspirate. <BR/>An interview on 12/10/24 at 12:15 PM with ADON I revealed the nurse on duty checked the food trays. She said for the mechanical soft diet, the meat was supposed to be soft and finely chopped. She said for Resident #6, sometimes he did not want his meat ground up. She said she was not aware of other residents getting the wrong textured meat and that no residents had choking incidents. <BR/>An interview on 12/10/24 at 1:48 PM with the DON revealed she did not know why Resident #6 did not receive ground meat on his lunch tray on 12/08/24. She said the resident did like to eat outside food and was able to eat whole hamburgers. She said she did not know what the facility policy said about mechanical soft diets. She said a resident who received the wrong textured meat was at risk for choking. <BR/>Review of the facility policy, Recommended Diets, dated 2019, reflected:<BR/>Mechanical Soft Diet<BR/>This diet is based on the Regular Diet or any other therapeutic diet. Modifications are made only in texture. This diet is designed for persons with chewing or swallowing difficulty. In addition to minced and moist meat or flaked fish served in sauce or gravy, with an average particle size of approximately 4 mm (slightly less than half a centimeter) in width and less than 15 mm (1 &frac12; centimeters) in length, some modifications are also made to the fruits and vegetables; most fruits and vegetables are not served raw, and others may be finely or coarsely chopped .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for four (Residents #1, #2, #3 and #4) of 13 residents reviewed for confidentiality of records. <BR/>The facility failed to ensure LVN A did not leave Residents #1, #2, #3, #4's medication blister packs on top of an unattended Medication cart while she was in Resident #4's room with the door closed. <BR/>This failure could place residents at risk of having their medical information exposed causing HIPAA violations with their personal information being known to other residents and visitors, resulting in embarrassment, frustration, and decreased psycho-social well-being. <BR/>The findings included:<BR/>Observation on 12/05/24 at 11:37 am to 11:46 am, Residents #1, #2, #3 and #4's medication blister cards were on top of and unattended medication cart. It was in front of Resident #4's room and the door was closed.<BR/>Record review of Resident #1's December 2024 MAR Printed 12/05/24 revealed, Letrozole Oral Tablet 2.5 MG (Letrozole) Give 1 tablet by mouth one time a day for breast cancer. <BR/>Record review of Resident #2's December 2024 MAR printed 12/05/24 revealed, Amlodipine Besylate Oral Tablet 5 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for Hypertension HOLD IF SBP (systolic blood pressure) IS &gt;100 OR HR (Heart Rate) &gt;60.<BR/>Record review of Resident #3's December 2024 MAR printed 12/05/24 revealed, Citalopram Hydrobromide Oral Tablet 20 MG Citalopram Hydrobromide) Give 0.5 tablet by mouth in the morning for depression.<BR/>Record review of Resident #4's December 2024 MAR printed 12/05/24 revealed, Levetiracetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet via G-Tube one time a day for seizure.<BR/>Interview on 12/05/24 at 11:47 am, LVN A stated she was getting ready to shred the resident's blister packs that were empty but she was rolling the medication cart down the hall and it looked like Resident #4 was about to fall out of bed. She stated she walked away from her medication cart and repositioned him while four residents medication blister packs were on top of the medication cart. She stated the blister pack labels showed Resident #1 was taking Letrozole 2.5 mg for breast cancer and Resident #2 took amlodipine 5 mg for blood pressure. She stated Resident #3 took citalopram 20 mg, for depression and Resident #4 took Keppra (Levetiracetam) 5 mg for seizures. She stated leaving blister packs unsecured could cause somebody to easily see what type of medications the residents took. She stated she had just come from room [ROOM NUMBER] and put the empty blister packs on top of the medication cart. She stated she should have put the blister packs in the medication cart until she was able to get to the shredder box at the nurses station, then taken them out to dispose. She stated she was wrong for leaving the blister packs on the medication cart and added she had a HIPAA training about two or three weeks ago. She stated the residents blister packs had the resident's first and last names, name of medication, dosage and for what the medication was taken. She stated for now on she would wait until she was in the area of the shredder box before taking the blister packs out. She stated leaving the resident's blister packs out and unattended could lead to somebody getting their information and aware of what types of medications they were on and for what they were taking them.<BR/>Interview on 12/05/24 at 5:26 pm, LVN B stated when the resident's blister packs were empty, they needed to tear the tops of off, because the resident's name were on them. He stated they did that because of the privacy of the patient rights because the blister packs had the resident's names and everything on them. He stated somebody could get the residents information and it was best to lock the empty blister packs in the med cart until they have time to take them to the shredder.<BR/>Interview on 12/06/24 at 2:54 pm, ADON C stated the nurses were supposed tear off the top part of the blister pack and put into the shredder and the bottom part went into the trash. She stated the LVN A situation the blister packs were turned over, faced down, so the patient info was not disclosed. She stated LVN A was on her way to shred those and stopped to see what was going on to help a resident who was about to fall. She stated LVN A was covered by HIPAA with the blister packs being turned face down and was all right to do that because she had an emergency. She stated she did not think she needed to secure the blister packs in the medication cart because they were okay face down. She stated the blister packs had the resident's names, medication name, dosage, dr name and some say what the diagnosed reason to take the medications. She stated the blister packs could cause a privacy issue if someone picked them up and whatever was on the card could be disclosed. <BR/>Interview on 12/06/24 at 5:41 pm, the DON stated the empty blister packs should go in a drawer of the med cart and as long as the nurse/med aid was with the med cart it's okay to have the empty blister packs upside down. She stated if the nurse or medication aide was away from the med cart they were supposed to lock the blister packs in med cart before the med cart was moved. She stated leaving a med cart with empty blister packs could be a HIPAA violation because anyone could touch them if the nurse/med aide was not at the med cart. She stated she was not aware LVN A closed Resident #4's room door with the med cart unattended with the four blister packs on the med cart. She stated the blister packs had the resident's names, medication name, date of birth , and diagnoses. She stated they definitely needed to Inservice train the staff about not leaving blister packs on the med carts unattended. <BR/>Interview on 12/06/24 6:51 pm, the Administrator stated she was notified yesterday LVN A was going to shred the resident's blister pack and saw her resident was close to falling out of bed so she ran into the room. She stated being told Resident #4 looked like he was about to fall. She stated LVN A_ could have put the empty blister packs in the med cart before she moved the med cart to prevent them from being left unattended. She stated the blister packs had the resident's name, medication name and date of birth . She stated they have had HIPAA trainings yesterday and had a 1:1 verbal warning with LVN A about HIPPAA. She stated the DON was responsible for ensuring staff following HIPAA procedure and unattended med carts with blister packs on top of them could result in other people finding out protected information about the residents. <BR/>Record review of the Facility's Training dated 12/05/24 by Trainer ADON C revealed, HIPAA/PHI: 1. Never leave items containing (PHI) unattended. 2. Keep empty medication cards and/or containers inside of the medication cart until you are ready to discard them. 3. If you are called away from your cart for any emergency be sure to place the medication cards back into the med cart and lock it. 4. Turning the medication cards face down is not acceptable because anyone can turn them over and have access to (PHI). 5. Discard items containing (PHI) in the appropriate shred box/container. Brief evaluation: I have been educated/counseled on HIPAA rules and proper storage and disposal of items containing (PHI). <BR/>Record review of the Facility's Resident Right policy undated revealed, Privacy and confidentiality - The resident has the right to personal privacy and confidentiality of his or her personal and medical records .3. The resident has the right to secure and confidential personal and medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain an effective pest control program to keep the facility free of pests.<BR/>The facility failed to ensure the facility was free from pests, including gnats.<BR/>The failure placed residents at risk of a decreased quality of life.<BR/>Findings included:<BR/>Record review of Resident #1's face sheet dated 6/8/23 revealed a [AGE] year-old female admitted to the facility 7/29/23 with diagnoses that included chronic respiratory failure, chronic diastolic heart failure, type 2 diabetes. Resident #1 was re admitted on [DATE].<BR/>Record review of Resident #2's face sheet dated 6/8/23 revealed a 80 year- old female admitted to the facility on [DATE] with diagnoses that included anemia, dementia, metabolic encephalopathy, hypertension and heart failure.<BR/>Observation and interview on 6/2/23 at 2:35 a.m. revealed there were 5-10 gnats flying around Resident #1's room. Resident #1 had a cup with paper covered straws which had 5-6 gnats sitting on the straws. Resident #1 stated the gnats had been in her room for several weeks and she had not received any pest control treatment.<BR/>Observation and interview on 6/2/23 at 2:45 revealed there were several gnats flying around Resident #2's room. There were to many gnats to count flying around the room and were not in any area of the room. Resident #2 stated the gnats had been in her room for a while however she was not sure of the exact time frame. Resident #2 stated she had not received any pest control treatment for the gnats.<BR/>Interview with the Administrator on 6/2/23 at 6:00PM with the administrator revealed pest control comes out once a week and he and the DON have a meeting with pest control to discuss areas that need attention. The Administrator revealed pest control was last at the facility on 5/16/23.<BR/>Record review of the pest control log revealed the facility was treated for ants on 5/16/23, 5/12/23, 5/15/123, 4/29/23, 4/28/23. There was no record of the facility being treated for gnats.<BR/>Review of the policy Pest control undated revealed This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.'

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness.Observations on 11/06/25 between 09:24 AM and 07:43AM revealed CMA A took a blood pressure cuff from the top of the medication cart, entered Resident #1's room, checked his blood pressure and put the blood pressure cuff back on the top of the medication carts without sanitizing it. CMA A gave Resident #1 his morning medications. CMA A moved the medication cart to the front of Resident #2's room. CMA A retrieved the blood pressure cuff from the top of the medication cart and checked Resident #2's blood pressure. CMA A returned to the medication cart and placed the blood pressure cuff on top of the medication cart, and again did not sanitize the cuff. CMA A gave Resident #2 her morning medications. In an interview with CMA A on 11/06/25 at 09:44 AM, she stated she cleaned the blood pressure cuff at the start of her shift this morning. She stated she cleaned the blood pressure cuff twice during her shift and added that she sanitized the blood pressure cuff between two residents' use. CMA A stated the risk of not cleaning the cuff between each resident was cross-contamination, spread of germs, and it could harm residents who were immunocompromised [low immune system]. In an interview with the Regional Nurse on 11/06/25 at 1:25 PM, he stated the staff were trained to disinfect the reusable equipment between residents' use. He stated the risk to the resident was the development of infection.In an interview with the ADON on 11/06/25 at 2:47 PM, she stated all staff were expected to follow infection control policy when in the building. She stated all equipment should be cleaned between patient-use according to the infection control policy. She stated there was an infection control policy specifically for equipment. The ADON stated the risk to the residents was cross contamination. Record review of the facility's policy titled Infection Control Policy & Procedure Manual 2019 UPDATED March 2023 reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.6. Resident care equipment and articles. 3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with approved disinfectant by the nursing assistant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 5 of 9 residents (Residents #1, #2, #7, #8, #9) reviewed for environment. <BR/>The facility failed to ensure Residents #1, #2, #7, #8, and #9 had hot water for washing and bathing in their rooms.<BR/>This failure affected residents by placing them at risk for a diminished quality of life.<BR/>Findings include:<BR/>Record review of Resident's #1 Face Sheet dated 1-20-2024, showed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #1 had a primary diagnosis of Multiple Sclerosis with unspecified protein-calorie malnutrition, calculus of kidney, muscle wasting and atrophy, and an unspecified disorder of the eyes.<BR/>In an observation of Resident #1's bathroom on 1-20-2024 at 4:40PM, it was discovered that Resident #1 did not have hot water in her bathroom. <BR/>Record review of Resident #2's Face Sheet dated 1-20-2024, showed a [AGE] year-old female with an admission date of 1-31-2020. Resident #2 had a primary diagnosis of unspecified sequelae of unspecified cerebrovascular disease, need assistance with personal care, protein-calorie malnutrition, and muscle wasting and atrophy. <BR/>In an interview with Resident #2, on 1/20/2024, at 4:44 PM, it was revealed that there wasn't hot water in her bathroom for weeks. It was observed that Resident #2 was in a wheelchair and in need of assistance with ADL. <BR/>In an observation of Resident #2's bathroom, on 1-20-2024, at 5:00 PM, it was confirmed that Resident #2 had no hot water in her bathroom. <BR/>Record review of Resident #7's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 8-29-2023. Resident #7 had a primary diagnosis of acute respiratory failure with hypoxia, and secondary diagnosis of hyperosmolality and hypernatremia, need for assistance with personal care, and acute metabolic acidosis. <BR/>In an interview with Resident #7, on 1/20/2024, at 5:15 PM, it was conveyed that Resident's bathroom hasn't had hot water for weeks. Resident #7 was observed to be bedfast and in need of ADL assistance. <BR/>In an observation of Resident #7's bathroom, on 1-20-2024, at 5:20 PM, it was confirmed Resident #7's bathroom was without hot water. <BR/>Record review of Resident #8's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an initial admission date of 11-29-2017. Resident #8 has a primary diagnosis of chronic viral hepatitis C, and secondary diagnosis of need for assistance with personal care, end stage renal disease, and muscle wasting and atrophy. Resident #8 was observed to be bedfast and in need of ADL assistance. <BR/>In an interview with Resident #8, on 1/20/2024, at 5:17 PM, it was revealed that Resident needs assistance with ADL. Resident #8 stated his room hasn't had hot water for over a week. <BR/>In an observation of Resident #8's bathroom, on 1-20-2024, at 5:20PM, it was revealed that Resident #8 did not have hot water in his bathroom. <BR/>Record review of Resident #9's Face Sheet, dated 1-20-2024, showed a [AGE] year-old male with an admission date of 10-8-2021. Resident #9 has a primary diagnosis of chronic obstructive pulmonary disease unspecified, and secondary diagnosis of parkinsonism, unsteadiness on feet, abnormalities of gait and mobility, and difficulty in walking. <BR/>Record review of the facility's list of residents in need of ADL assistance, dated 1-20-2024, revealed Resident #9 to be included. <BR/>In an interview with Resident #9, on 1/20/2024, at 6:05 PM, it was revealed that Resident #9's room hasn't had hot water for over a week. <BR/>In an observation of Resident #9's bathroom, on 1-20-2024 at 6:10 PM, it was confirmed that Resident #9 had no hot water in his bathroom. <BR/>In an interview with the Director of Maintenance by phone, it was revealed he is offsite up north. The Director of Maintenance said there was hot water in the lines, but he thinks the mixing valve is defective, which could be causing the water, in the 300 area, to not be hot in the resident's rooms. However, he was not sure if that was the problem. The Director of Maintenance said they were waiting on a part to come in Monday to see if that fixes the problem. The Director of Maintenance stated that the water temperature has dropped below 102 degrees Fahrenheit, in the line, but not over 2 weeks. The Director of Maintenance would not say how long the water temperature has been a problem. <BR/>In an interview with the Administrator, on 1/20/2024, at 7:00 PM, it was revealed that his expectation was that residents have hot water in their bathrooms. The Administrator stated that one of their tankless water heaters had to be replaced and the control valve that adjusts the heat wasn't working. The Administrator stated that a part has been ordered and should be at the facility next week. The Administrator said was the Director of Maintenance's responsibility to ensure residents have hot water in their bathrooms. <BR/>In an interview with the DON, on 1-20-2024, at 7:38 PM, it was learned that her expectation was that residents be taken to units that do have hot water to use. The DON stated that when residents do not have hot water in their restrooms, it could be an infection control issue. The DON said the facility had a problem with hot water in the 300-room domain. The DON stated it was everyone's responsibility to make sure residents have hot water and report it when residents don't. <BR/>Record Review of the facility's undated Hot Water Systems Policy stated the hot water system will be checked daily to include shower temperatures. The water temperatures should be maintained at 100 degrees Fahrenheit minimum .<BR/>13.Temperature readings will be recorded on the water temperature log. <BR/>14. <BR/>The hot water tanks should be adjusted accordingly with readings that are too high or too low. Adjustments will be noted on the water temperature log.<BR/>15. <BR/>After adjustments are made, the temperature must be rechecked within thirty minutes of the adjustment. If the water continues to be too hot or too cold, the Administrator should be notified immediately.<BR/>16. <BR/>The facility will make provisions to repair the hot water problem as soon as possible. Use to the areas affected by the malfunctioning unit will be restricted until repairs are complete.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness.Observations on 11/06/25 between 09:24 AM and 07:43AM revealed CMA A took a blood pressure cuff from the top of the medication cart, entered Resident #1's room, checked his blood pressure and put the blood pressure cuff back on the top of the medication carts without sanitizing it. CMA A gave Resident #1 his morning medications. CMA A moved the medication cart to the front of Resident #2's room. CMA A retrieved the blood pressure cuff from the top of the medication cart and checked Resident #2's blood pressure. CMA A returned to the medication cart and placed the blood pressure cuff on top of the medication cart, and again did not sanitize the cuff. CMA A gave Resident #2 her morning medications. In an interview with CMA A on 11/06/25 at 09:44 AM, she stated she cleaned the blood pressure cuff at the start of her shift this morning. She stated she cleaned the blood pressure cuff twice during her shift and added that she sanitized the blood pressure cuff between two residents' use. CMA A stated the risk of not cleaning the cuff between each resident was cross-contamination, spread of germs, and it could harm residents who were immunocompromised [low immune system]. In an interview with the Regional Nurse on 11/06/25 at 1:25 PM, he stated the staff were trained to disinfect the reusable equipment between residents' use. He stated the risk to the resident was the development of infection.In an interview with the ADON on 11/06/25 at 2:47 PM, she stated all staff were expected to follow infection control policy when in the building. She stated all equipment should be cleaned between patient-use according to the infection control policy. She stated there was an infection control policy specifically for equipment. The ADON stated the risk to the residents was cross contamination. Record review of the facility's policy titled Infection Control Policy & Procedure Manual 2019 UPDATED March 2023 reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.6. Resident care equipment and articles. 3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with approved disinfectant by the nursing assistant.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness.Observations on 11/06/25 between 09:24 AM and 07:43AM revealed CMA A took a blood pressure cuff from the top of the medication cart, entered Resident #1's room, checked his blood pressure and put the blood pressure cuff back on the top of the medication carts without sanitizing it. CMA A gave Resident #1 his morning medications. CMA A moved the medication cart to the front of Resident #2's room. CMA A retrieved the blood pressure cuff from the top of the medication cart and checked Resident #2's blood pressure. CMA A returned to the medication cart and placed the blood pressure cuff on top of the medication cart, and again did not sanitize the cuff. CMA A gave Resident #2 her morning medications. In an interview with CMA A on 11/06/25 at 09:44 AM, she stated she cleaned the blood pressure cuff at the start of her shift this morning. She stated she cleaned the blood pressure cuff twice during her shift and added that she sanitized the blood pressure cuff between two residents' use. CMA A stated the risk of not cleaning the cuff between each resident was cross-contamination, spread of germs, and it could harm residents who were immunocompromised [low immune system]. In an interview with the Regional Nurse on 11/06/25 at 1:25 PM, he stated the staff were trained to disinfect the reusable equipment between residents' use. He stated the risk to the resident was the development of infection.In an interview with the ADON on 11/06/25 at 2:47 PM, she stated all staff were expected to follow infection control policy when in the building. She stated all equipment should be cleaned between patient-use according to the infection control policy. She stated there was an infection control policy specifically for equipment. The ADON stated the risk to the residents was cross contamination. Record review of the facility's policy titled Infection Control Policy & Procedure Manual 2019 UPDATED March 2023 reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.6. Resident care equipment and articles. 3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with approved disinfectant by the nursing assistant.

Based on record review, observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for one (medication cart #1) of two medication carts observed for medication storage. On 06/09/25 at 7:53 AM, MT Q failed to ensure medications were secured or attended to by authorized staff when MT Q did not lock the medication cart (#1) before she walked away. This failure placed residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion. Findings included: During an observation on 06/09/25 at 7:53 AM revealed a medication cart (#1) unlocked, unattended and not under direct observation of authorized staff. The lock was in the out position, and anyone could open the drawers and left the medications accessible. Various multi-dose bottles of OTC medications were organized in the top drawer of the medication cart. Residents' routine and PRN medications and medication blister packs were organized in other drawers of the medication cart. One resident was ambulating back and forth in the hallway during observation. At 7:55 AM, the Investigator observed MT Q walking towards the medication cart from approximately twenty-five feet away. During an interview on 06/09/25 at 7:56 AM, MT Q said she did not normally leave the medication cart I#1) unlocked when she walked away. MT Q stated she was only right there and pointed at a resident room down the hall, it was her fault, and she knew that leaving the medication cart unlocked and walking away should never happen. MT Q said she received training during new hire orientation. MT Q stated a resident could get a hold of medications and have an allergic reaction. During an interview on 06/09/25 at 12:31 PM, the DON who said that it was not acceptable to leave medication carts unlocked and unattended or not within direct line of site and arms reach for resident safety and to prevent drug diversion. The DON said if residents could access the medications, swallow a medication that they are allergic to, could have an adverse reaction. The DON said she would conduct an in-service about medication storage and safety. The DON stated surveillance of medication carts being locked were conducted regularly for quality assurance. Review of the facility's policy Medication Storage - Storage of Medication, dated 05/16, reflected:- In order to limit access to prescription medication, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts. medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on record review, observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for one (medication cart #1) of two medication carts observed for medication storage. On 06/09/25 at 7:53 AM, MT Q failed to ensure medications were secured or attended to by authorized staff when MT Q did not lock the medication cart (#1) before she walked away. This failure placed residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion. Findings included: During an observation on 06/09/25 at 7:53 AM revealed a medication cart (#1) unlocked, unattended and not under direct observation of authorized staff. The lock was in the out position, and anyone could open the drawers and left the medications accessible. Various multi-dose bottles of OTC medications were organized in the top drawer of the medication cart. Residents' routine and PRN medications and medication blister packs were organized in other drawers of the medication cart. One resident was ambulating back and forth in the hallway during observation. At 7:55 AM, the Investigator observed MT Q walking towards the medication cart from approximately twenty-five feet away. During an interview on 06/09/25 at 7:56 AM, MT Q said she did not normally leave the medication cart I#1) unlocked when she walked away. MT Q stated she was only right there and pointed at a resident room down the hall, it was her fault, and she knew that leaving the medication cart unlocked and walking away should never happen. MT Q said she received training during new hire orientation. MT Q stated a resident could get a hold of medications and have an allergic reaction. During an interview on 06/09/25 at 12:31 PM, the DON who said that it was not acceptable to leave medication carts unlocked and unattended or not within direct line of site and arms reach for resident safety and to prevent drug diversion. The DON said if residents could access the medications, swallow a medication that they are allergic to, could have an adverse reaction. The DON said she would conduct an in-service about medication storage and safety. The DON stated surveillance of medication carts being locked were conducted regularly for quality assurance. Review of the facility's policy Medication Storage - Storage of Medication, dated 05/16, reflected:- In order to limit access to prescription medication, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications are allowed access to medication carts. medication supplies should remain locked when not in use or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness.Observations on 11/06/25 between 09:24 AM and 07:43AM revealed CMA A took a blood pressure cuff from the top of the medication cart, entered Resident #1's room, checked his blood pressure and put the blood pressure cuff back on the top of the medication carts without sanitizing it. CMA A gave Resident #1 his morning medications. CMA A moved the medication cart to the front of Resident #2's room. CMA A retrieved the blood pressure cuff from the top of the medication cart and checked Resident #2's blood pressure. CMA A returned to the medication cart and placed the blood pressure cuff on top of the medication cart, and again did not sanitize the cuff. CMA A gave Resident #2 her morning medications. In an interview with CMA A on 11/06/25 at 09:44 AM, she stated she cleaned the blood pressure cuff at the start of her shift this morning. She stated she cleaned the blood pressure cuff twice during her shift and added that she sanitized the blood pressure cuff between two residents' use. CMA A stated the risk of not cleaning the cuff between each resident was cross-contamination, spread of germs, and it could harm residents who were immunocompromised [low immune system]. In an interview with the Regional Nurse on 11/06/25 at 1:25 PM, he stated the staff were trained to disinfect the reusable equipment between residents' use. He stated the risk to the resident was the development of infection.In an interview with the ADON on 11/06/25 at 2:47 PM, she stated all staff were expected to follow infection control policy when in the building. She stated all equipment should be cleaned between patient-use according to the infection control policy. She stated there was an infection control policy specifically for equipment. The ADON stated the risk to the residents was cross contamination. Record review of the facility's policy titled Infection Control Policy & Procedure Manual 2019 UPDATED March 2023 reflected The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.6. Resident care equipment and articles. 3. Non-invasive resident care equipment is cleaned daily or as need between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with approved disinfectant by the nursing assistant.